Confidential Daily Journal
Write as much or as little as you like, as often as you like, as a journal entry on this journey to attaining a healthier life.
Email address *
Synergy Counseling Center
Honesty is the best policy.
Q1 *
First Name
Q2 *
Last Name
Q3 *
Today's Date
MM
/
DD
/
YYYY
Q4 *
Did you go to work or school today?
Q5 *
Did you eat breakfast today?
Q6 *
How many cigarettes did you smoke yesterday?
Q7 *
Is it your goal to stop smoking?
Q8 *
How many glasses of water did you drink yesterday?
None
10 or more glases
Q9 *
How many alcoholic drinks did you drink yesterday?
Drinks (beer, wine, mixed drinks, etc.)
Drinks (beer, wine, mixed drinks, etc.)
Q10 *
Is total abstinence from alcohol your long-term goal?
Q11 *
How much Suboxone did you take yesterday (a prescribed medication)?
Q12 *
(Illegal substance use.) How many pain pills, opioids, benzos, marijuana, etc. did you have yesterday?
Q13 *
Did you exercise yesterday (or have you been active today)?
Q14 *
How many hours of sleep did you get last night?
Hours
Hours
Q15 *
Do you get up at the same time each morning?
Q16 *
What time did you go to bed last night?
Q17 *
What time did you get up this morning?
Q18 *
What are your goals this week?
Q19 *
How many calories (or carbs) did you consume yesterday?
Q20 *
How depressed were you yesterday?
Not At All
Very
Q21 *
How anxious were you yesterday?
Not At All
Very
Q22 *
How bad is your addiction craving right now?
Not At All
Very Bad
Q23 *
Did you do anything illegal yesterday?
Q24 *
Did you take your medication as prescribed yesterday?
Q25 *
Your weight today?
Q26 *
Blood Pressure:
Q27 *
Heart Rate (Pulse):
Q28 *
List the persons, situations, and other triggers of anger or discomfort today.
Q29 *
Record thoughts, feelings, and actions taken as the result of anger or discomfort today.
Q30 *
What do you need to get off your chest today?
Thank you!
You are finished. Your answers are kept strictly confidential.
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