Porn Recovery Daily Questionnaire

Date Date:

Participant Who are you?

Porn Use

Did you view porn intentionally?

No
Yes

On a scale of 1–5, how intense was the relapse? (0 if didn't relapse)

Total time spent viewing porn today (minutes):

Masturbation

Did you masturbate today?

No
Yes, with porn
Yes, without porn

Urges Peak urge intensity today (0–10):

Approximate number of urge episodes today:

Longest urge duration (minutes):

Did you act on the urge?

No
Yes

Wellbeing Hours of sleep:

Sleep quality (1–5):

Mood today (1–5):

Energy level (1–5):

Motivation level (1–5):

Stress level (1–5):

Confidence level (1–5):

Task accomplishment (1–5):

Emotions felt today (check all that apply):

Stress
Loneliness
Anxiety
Boredom
Sadness
Anger
Other:

Resistance & Distraction

Did you try to resist or distract yourself?

No
Yes

What did you do to distract yourself?

Exercise
Go outside
Journaling
Other:

Effectiveness of resistance (1–5):

Motivation & Mindset Motivation to stay porn-free (1–10):

Confidence to resist urges (1–10):

Sense of purpose/meaning (1–5):

Shame or guilt felt (1–5):

Comment