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
Would you want to share any other information?
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