Work-Related Health Impact Analyzer

Date:

Start Time:

End Time:

Type of Work/Activity:

Perceived Work Intensity:

Date	Time	Duration	Work Type	Intensity	Actions

Date:

Time of Log (Optional):

Stress Level (1 Low - 5 High):

Energy Level (1 Low - 5 High):

Overall Mood (1 Neg - 5 Pos):

Physical Symptoms Experienced (Check all that apply):

Positive Impacts Felt (Optional, check all that apply):

General Well-being Notes:

Date	Stress	Energy	Mood	Symptoms	Positive Impacts	Notes	Actions

Analysis Start Date:

Analysis End Date: