Mental Health Survey

Name *

Email *

Age

Gender

1. Overall how would you rate your physical health?

2. Overall how would you rate your mental health?

3. During the past 4 weeks, have you had any problems with your work or daily life due to your physical health?

Yes
No
Not sure

4. During the past 4 weeks, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad or anxious?

Yes
No
Not sure

5. During the past 4 weeks, how often has your mental health affected your ability to get work done?

Very often
Somewhat often
Not so often
Not at all

6. Have you felt particularly low or down for more than 2 weeks in a row?

Very often
Somewhat often
Not so often
Not at all

7. During the past two weeks, how often has your mental health affected your relationships?

Very often
Somewhat often
Not so often
Not at all

8. How often do you experience below?

Calm & peaceful

Energetic

Gloomy

Angry

9. Have you noticed any change in your diet habits?

Yes, I eat too much
Yes, I don't feel hungry
Not much
No change

10. When was the last time you were really happy?

11. When was the last time you felt good about yourself?

12. How often do you feel positive about your life?

13. When was the last time you had a positive outlook on life?

14. Have you ever been diagnosed with a mental disorder before?

Yes
No
Not sure

15. When did you last get your mental health examination done?

16. Is there a history of mental disorder in your family?

Yes
No
Not sure

17. If "Yes", please select which of the family member(s) had a history of mental illness.

18. Does your health limit you in doing daily activities?

Light physical activities

Very less
Moderately
Very much
No problem

Moderate physical activities

Very less
Moderately
Very much
No problem

Heavy physical activities

Very less
Moderately
Very much
No problem

19. Have you seen a therapist in the recent past?

Yes
No
Not sure

20. Are you currently taking any medication?

Yes
No

21. How many hours do you sleep per day?

Less than 4
4-6
7-9
9+

22. How is your quality of sleep?

23. What is your relationship status?

24. Do you feel content with your relationships and family?

Yes
Sometimes
No

25. How often do you smoke?

Never
Once in few weeks
Once everyday
More than once everyday

26. How often do you drink?

Never
Once in few weeks
Once everyday
More than once everyday

27. Have you changed your job recently?

Yes
No
NA

28. Have you changed your routine recently?

Yes, quite a bit
Yes, slightly
Not at all

29. Are you going through a tough emotional situation?

Yes
No

30. Do you want to share any other information?