Mental Health Survey

Mental Health Survey
General Evaluation
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?

Please note, all the fields are required.
1. Little interest or pleasure in doing things

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
2. Feeling down, depressed or hopeless

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
3. Trouble falling or staying asleep or sleeping too much

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
4. Feeling tired or having little energy

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
5. Poor appetite or overeating

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
6. Feeling bad about yourself - or that you are a failure or have let yourself or family down

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
7. Trouble concentrating on things such as reading the newspaper or watching TV

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
8. Moving or speaking so slowly that other people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
9. Thoughts that you would be better off dead or of hurting yourself

1

2

3

4

5

1 is NEVER, 5 is EVERY DAY
10. If you checked off any problems, how difficult have these problems made it for you at work, home or with other people?
About Your Mental Health
YesNo
YesNo
CoronavirusRacismRelationship problemsPast traumaCurrent events (news, politics, etc.)Loneliness or isolationGrief or loss of someone or somethingFinancial problemsOther
About Your Health
YesNo
Heart DiseaseDiabetesCancerArthritis or other chronic painCOPD or other lung conditionsMovement disordersHIV/AIDSOther
About You
Age Range
Gender
Race/Ethnicity
Household Income
Veteran or active duty militaryCaregiver of someone living with emotional or physical illnessLGBTQ+StudentTrauma survivorNew or expecting motherHealthcare worker
Should be Empty:

Mental Health Survey

General Evaluation

About Your Mental Health

About Your Health

About You