Mental Health Survey

What is your gender?

Male

Female

Other

Prefer not to say

During the past 4 weeks, have you had any problems with your work due to your physical health?

Yes

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

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

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

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

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

Not sure

Is there a history of mental disorder in your family?

Yes

Not sure

Are you currently going through a tough emotional situation?

Yes

Would you want to share any other information?

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	Never	Once in a while	About half the time	Most of the time	Always
Calm and peaceful
Energetic
Gloomy
Overwhelmed
Angry