Mental Health Metrics Monitoring Form
Please fill out the following to help us monitor your mental health status.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Assessment
-
Month
-
Day
Year
Date
On a scale of 1 to 5, how would you rate your current stress level?
1
2
3
4
Best
5
1 is , 5 is Best
On a scale of 1 to 5, how would you rate your current mood?
1
2
3
4
Best
5
1 is , 5 is Best
How many hours of sleep did you get last night?
How often do you engage in physical activity per week?
Please Select
Never
1-2 times
3-4 times
5 or more times
Let’s explore anxiety
We’ll use the GAD-7 to understand any anxiety symptoms you may be experiencing. Please read through each statement and think about how often you’ve felt this way in the last 2 weeks.
Are you feeling anxious, nervous
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it is hard to sit
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
How’s your mood been recently?
This assessment uses the PHQ-9 questionnaire to help evaluate symptoms related to depression and emotional well-being. Please review each statement carefully and select how often you have experienced these feelings over the past 2 weeks.
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
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
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or of hurting yourself
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not at all
Several days
More than half the days
Nearly every day
Additional Comments
Submit
Should be Empty: