Impulse Resistance Log
Record your experiences resisting impulses to track progress and identify helpful strategies.
Date and Time of Impulse Episode
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Impulse (e.g., food, shopping, smoking, etc.)
*
Please Select
Food Craving
Shopping Urge
Smoking
Alcohol
Social Media
Gambling
Other
Describe the Situation or Context
*
What triggered the impulse?
*
Emotional State (e.g., stress, boredom)
Environmental Cue (e.g., seeing, smelling)
Social Influence
Routine/Habit
Other
How intense was the impulse?
*
Not intense at all
1
2
3
4
5
6
7
8
9
Extremely intense
10
1 is Not intense at all, 10 is Extremely intense
Strategy Used to Resist the Impulse
*
Distraction (e.g., walk, call a friend)
Delay/Wait it out
Cognitive Reframing (changing thoughts)
Mindfulness/Breathing
Other
Outcome of the Episode
*
Successfully Resisted
Partially Resisted
Did Not Resist
How difficult was it to resist?
*
Very easy
1
2
3
4
5
6
7
8
9
Very difficult
10
1 is Very easy, 10 is Very difficult
Emotional State Before and After the Episode
*
Rows
Before
After
Emotional State
Calm
Anxious
Sad
Happy
Frustrated
Bored
Other
Calm
Anxious
Sad
Happy
Relieved
Proud
Frustrated
Other
Notes or Reflections (what did you learn, what would you do differently?)
Signature (optional, for accountability or professional review)
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Should be Empty: