If I can ask, what is this for? What I would write would depend on the form and reason behind it.

Without that information though I would probably put 2 different scenarios. Have a 'good day' and a 'bad day' and then write what would cause it to be 'good' or 'bad' and what you would most likely do on those days. Exactly like here.

On a good day I _______ (get up, get dressed, breakfast etc.)

On a bad day it varies. If I have not slept I _______. If I am feeling low I ________. If I am very stressed I ________.

Again, for me it would really depend on what the form was for but if you are wanting to be as honest as possible I would give the main scenarios that affect you