Mental Health Survey
What is your age?
18-24
25-29
30-34
35-39
40+
Prefer not to answer
What is your gender?
Male
Female
Other
Prefer not to say
Overall, how would you rate your physical health?
Excellent
Somewhat good
Average
Somewhat poor
Poor
Not sure
Overall, how would you rate your mental health?
Excellent
Somewhat good
Average
Somewhat Poor
Poor
Not sure
During the past 4 weeks, have you had any problems with your work due to your physical health?
Yes
No
Not sure
During the past 4 weeks, have you had any problems with your work due to any emotional distress, such as feeling depressed, overwhelmed, or anxious?
Yes
No
Not sure
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
During the past 2 weeks, how often has your mental health affected your relationships?
Very often
Somewhat often
Not so often
Not at all
How often do you experience the following?
Never | Once in a while | About half the time | Most of the time | Always | |
|---|---|---|---|---|---|
Calm and peaceful | |||||
Energetic | |||||
Gloomy | |||||
Overwhelmed | |||||
Angry |
When was the last time you felt the following?
Within the last few days | Within the last few weeks | Within the last few months | Never | I don't remember | |
|---|---|---|---|---|---|
Felt good about yourself | |||||
Felt really happy | |||||
Felt positive about your life | |||||
Felt positive about your work |
How often do you take the time to practice the following to relax your mind?
Not at all | Not so often | Somewhat often | Very often | |
|---|---|---|---|---|
Breath focus: take slow, deep breaths in through your nose and out through your mouth | ||||
Body scan: progressively release physical tension and relax the muscles throughout your body | ||||
Guided imagery: conjure up soothing scenes, places, or experiences in your mind | ||||
Mindful meditation: sit comfortably, focus on your breathing, and focus on the present moment (not the past or future) | ||||
Yoga, tai chi, and qigong: arts combining rhythmic breathing with a series of postures or flowing movements | ||||
Repetitive prayer: silently repeat and short prayer or phrase while practicing breath focus |
If you don't currently practice relaxing your mind, would you try it the next time you feel mentally overwhelmed?
Yes
No
Not sure
During the past 4 weeks, have you noticed any changes in your diet habits?
Yes, I eat too much
Yes, I don't feel hungry
Not much
No change
In the past 4 weeks, how many hours do you sleep per day?
Less than 4
4-6
7-9
9+
In the past 4 weeks, how would you rate your quality of sleep?
Very bad
Bad
Normal
Good
Very good
In the past 4 weeks, how often have you smoked or used tobacco products?
Never
Once in a while
Once everyday
More than once everyday
In the past 4 weeks, how often have you cosumed alcohol?
Never
Once in a while
Once everyday
More than once everyday
Have you ever been diagnosed with a mental disorder before?
Yes
No
Not sure
Is there a history of mental disorder in your family?
Yes
No
Not sure
Are you currently going through a tough emotional situation?
Yes
No
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