Mental Health Questionnaire
Patient Name
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
In the last two weeks, how often have you been bothered by:
Feeling nervous, anxious or on edge?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Not being able to stop or control worrying?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Worrying too much about different things?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Trouble relaxing?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Being so restless that it's hard to sit still?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Becoming easily annoyed or irritable?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Feeling afraid as if something awful might happen?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Little interest or pleasure in doing things?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Feeling down, depressed, or hopeless?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Trouble falling or staying asleep, or sleeping too much?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Feeling tired or having little energy?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Poor appetite or overeating?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
Not at all. 0
Several days. 1
More than half the days. 2
Most of the days. 3
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