Mental Wellbeing Assessment
Name
*
First Name
Last Name
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at All
Several Days
More than half the days
Nearly Every Day
1. Feeling nervous, anxious or on edge
1
2
3
4
2. Not being able to stop or control worrying
5
6
7
8
3. Worrying too much about different things
9
10
11
12
4. Trouble relaxing
13
14
15
16
5. Being so restless that it is hard to sit still
17
18
19
20
6. Becoming easily annoyed or irritable
21
22
23
24
7. Feeling afraid as if something awful might happen
25
26
27
28
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at All
Several Days
More than half the days
Nearly Every Day
1. Little interest or pleasure in doing things
29
30
31
32
2. Feeling down, depressed, or hopeless
33
34
35
36
3. Trouble falling or staying asleep, or sleeping too much
37
38
39
40
4. Feeling tired or having little energy
41
42
43
44
5. Poor appetite or overeating
45
46
47
48
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
49
50
51
52
7. Trouble concentrating on things, such as reading the newspaper or watching television
53
54
55
56
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
57
58
59
60
9. Thoughts that you would be better off dead or of hurting yourself in some way
61
62
63
64
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 difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Additional information if you need.
Submit
Should be Empty: