• Mental Health Questionnaire

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Over the past two weeks, how often have you been bothered by any of the following problems?*
    Rows
  • If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?*
  • Over the past two weeks, how often have you been bothered by any of the following problems?*
    Rows

  • Please read each statement and mark a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

    The rating scale is as follows:

    0: Did not apply to me at all - NEVER

    1: Applied to me to some degree, or some of the time - SOMETIMES

    2: Applied to me to a considerable degree, or a good part of the time - OFTEN

    3: Applied to me very much, or most of the time - ALMOST ALWAYS

  • Type a question*
    Rows
  • Should be Empty:
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