Depression Self-Care Checklist Form
This Depression Self-Care Checklist Form helps you reflect on your recent self-care activities, coping strategies, and support use. Please answer honestly to help track your current self-care routine.
Which self-care activities have you practiced in the past week? (Select all that apply)
*
Getting enough sleep
Eating regular meals
Physical exercise
Spending time outdoors
Relaxation or mindfulness
Creative activities (music, art, etc.)
Connecting with friends or family
Other
How would you rate your sleep quality over the past week?
*
1
2
3
4
5
How often have you eaten regular, balanced meals this week?
*
Every day
Most days
Some days
Rarely
How would you describe your physical activity this week?
*
Active every day
Active most days
Active some days
Not active this week
How much social interaction have you had this week?
*
Plenty of interaction
Some interaction
Minimal interaction
None
Which coping strategies have you used to manage stress or low mood? (Select all that apply)
*
Talking to someone I trust
Writing in a journal
Practicing mindfulness or meditation
Engaging in hobbies
Seeking online support
Other
How often have you used support resources (such as helplines, apps, or groups) this week?
*
Frequently
Sometimes
Rarely
Not at all
On a scale from 1 to 5, how would you rate your current stress level?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
How would you rate your overall mood over the past week?
*
1
2
3
4
5
Would you like to receive information or resources about self-care or support options?
*
Yes, please send me resources
No, thank you
Is there anything else you would like to share about your self-care experience?
Submit
Should be Empty: