POZ232_December

Healthy Mind
A cancer diagnosis can be scary. It can cause anxiety and depression and have an impact on one's mental health. If you are experiencing mental health issues, it’s important to recognize the signs and seek help. Please tell Cancer Health about your mental health by completing this survey.
1) How would you rate your overall mental health?

ExcellentGoodAveragePoor
2) During the last two weeks, how often have you felt sad or depressed?

Most of the timeOftenOccasionallyNot at all
3) During the last two weeks, how often have you felt nervous, anxious or on edge?

Most of the timeOftenOccasionallyNot at all
4) During the last two weeks, how often have you had trouble sleeping or slept too much?

Most of the timeOftenOccasionallyNot at all
5) During the last two weeks, how often have you had trouble concentrating or paying attention?

Most of the timeOftenOccasionallyNot at all
6) Do you ever have suicidal thoughts or feel like you want to harm yourself?

YesNo
7) How often does your mental health interfere with your personal relationships?

Most of the timeOftenOccasionallyNot at all
8) How often does your mental health interfere with your health care?

Most of the timeOftenOccasionallyNot at all
9) How often does your mental health interfere with your ability to get work done?

Most of the timeOftenOccasionallyNot at all
10) Have you ever been diagnosed with a mental health condition (such as depression, anxiety or bipolar disorder)?

YesNo
11) Is there a history of mental health conditions in your family?

YesNo
12) Have you ever undergone treatment for a mental health condition?

YesNo
13) Have you ever had difficulty accessing mental health services?

YesNo
14) What year were you born?
15) What is your gender?

MaleFemaleTransgenderOther
16) What is your sexual orientation?

StraightGay/LesbianBisexualOther
17) What is your ethnicity? (Check all that apply.)

American Indian or Alaska NativeArab or Middle EasternAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther
18) What is your current level of education?

Some high schoolHigh school graduateSome collegeBachelor’s degree or higher
19) What is your annual household income?

Less than $15,000$15,000–$34,999$35,000–$49,999$50,000–$74,999$75,000–$99,999$100,000 or more
20) What is your zip code?
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Healthy Mind