Emotion Translation Sample Form
Please complete this form to help us capture and translate your current emotional state into a structured record.
Full Name
First Name
Last Name
Date and Time of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary Emotion You Are Experiencing
*
Please Select
Happiness
Sadness
Anger
Fear
Surprise
Disgust
Calm
Other
How intense is this emotion right now?
*
Not intense
1
2
3
4
5
6
7
8
9
Extremely intense
10
1 is Not intense, 10 is Extremely intense
What triggered this emotion?
Which of the following best describes your current environment?
Alone
With friends
With family
At work/school
Public place
Other
How well do you understand your current emotion?
*
1
2
3
4
5
Select a word that best translates your emotion into a structured category
*
Please Select
Joy
Grief
Frustration
Anxiety
Contentment
Excitement
Other
How would you like to respond to this emotion?
Accept it
Change it
Express it
Suppress it
Not sure
Additional comments or context (optional)
Submit
Should be Empty: