Mental Health Screening
[Survey by SPMHC - NGO]
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:
Family History of Psychiatry Illness
Cancer
Physical Health Conditions
Hypertension
Psychiatric disorder
Diabetes
Relationship / Family Problems
Other
Check the symptoms that you' re currently experiencing:
Reduced Sleep
Isolation
Suicidal Thoughts
Fearful, Tensed
Inattention
Low Mood
Agitated
Low Sexual Desire
Low Energy
Poor Functioning
Weight gain
Weight loss
Feels Low Energy
Other
Have you seen a Psychiatrist / Psychologist in the recent past?
Yes
No
Not Sure
Are you currently taking any medication?
Yes
No
In the past month, approximately how many hours per day spent using a screen? (Includes computer, game consoles, cell phone, or TV)?
Please Select
1-3
3-6
>6
Do you use any kind of tobacco / illegal drugs or have you ever used them?
Please Select
Yes
No
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Do you want to share any other information, so that our Psychologist may extend help?
Submit
Should be Empty: