Mental and Emotional Wellbeing Questionnaire

How often have you been bothered by feeling down, depressed or hopeless?

1

2

3

Not at all

How often have you had little interest or pleasure in doing things?

1

2

3

Not at all

How often have you been bothered by trouble falling or staying asleep, or sleeping too much?

1

2

3

Not at all

How often have you been bothered by feeling tired or having little energy?

1

2

3

Not at all

How often have you been bothered by poor appetite or overeating?

1

2

3

Not at all

How often have you been bothered by feeling bad about yourself, or that you are a failure, or have let yourself or your family down?

1

2

3

Not at all

How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?

1

2

3

Not at all

RadioHow often have you been bothered by moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?

1

2

3

Not at all

Thoughts that you would be better off dead, or of hurting yourself in some way?

1

2

3

Not at all

Have you had an anxiety attack (suddenly feeling fear or panic)?

1

2

3

Not at all

How often have you been bothered by feeling nervous, anxious or on edge?

1

2

3

Not at all

How often have you been bothered by not being able to stop or control worrying?

1

2

3

Not at all

How often have you been bothered by worrying too much about different things?

1

2

3

Not at all

How often have you been bothered by having trouble relaxing?

1

2

3

Not at all

How often have you been bothered by being so restless that it is hard to sit still?

1

2

3

Not at all

How often have you been bothered by becoming easily annoyed or irritable?

1

2

3

Not at all

How often have you been bothered by feeling afraid as if something awful might happen?

1

2

3

Not at all

Your Name

First Name

Last Name

Date

MM

DD

YYYY