Mental Health Questionnaire

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Mental Health Questionnaire

Instructions-

1. Please fill in all the details.

2. Read the question properly and score yourself accordingly.

3. For starting questions- 1 is scored as the lowest and 9 as the highest.

4. In middle questions - 1 is scored as the highest and 9 as the lowest.

5. In the end questions- multiple checkboxes can be done wherever required as per you.

6. Take your time to read the question.

7. All the questions are mandatory.

8. Responses will be confidential and will not be shared with anyone except the Certified Psychologist.

9. Result will be shared only with you in 15-20 days.

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Name *

Gender *

Contact Details *

Father's Name *

Residential Address *

Department *

Employee ID *

School/College Name *

Assess your: Adaptability to Change

"Your ability to be flexible when faced with societal changes, or changes in your daily routine or environment, and to adopt new ways of living or working accordingly"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Creativity & Problem Solving

"Your imagination, artistic expression and your ability to generate novel ideas and find solutions to problems"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Self Worth & Confidence

"Your ability to think highly of yourself and demonstrate appropriate levels of confidence and self-belief"
*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Drive & Motivation

"Your ability and desire to initiate, persevere with and complete effortful tasks and activities"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Stability & Calmness
"Your ability to approach situations consistently and calmly without uncontrolled emotion."

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Sleep Quality
"Your ability to easily fall asleep, stay asleep during the night and wake up feeling rested"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Self Control & Impulsivity
"Your ability to demonstrate appropriate levels of self control in your thoughts and actions and to regulate your impulsivity"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Ability to Learn
"Your ability to incorporate new information and concepts into your existing knowledge and to pick up new skills"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Relationships with others
"Your ability to form secure, enduring and meaningful connections and emotional bonds with family and peers"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Emotional Resilience
"Your ability to bounce back and restore your emotional balance after setbacks"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Planning & Organisation
"Your ability to prioritize and keep track of tasks and activities and form realistic expectations for the future”

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Speech & Language
"Your ability to formulate sentences and make yourself understood to others"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Memory
"Your ability to hold important information in your mind, recall past events and factual knowledge, and perform learned skills"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Social interactions & Cooperation
"Your ability to engage, interact, and work together with others using your verbal and nonverbal communication skills such as appropriate eye contact

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Decision-making & Risk-taking
"Your ability to analyze the possible outcomes and risks of a situation and make choices quickly and effectively "

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Curiosity, Interest & Enthusiasm
"Your ability to explore, understand and try new things in the world and excitement to participate in activities with the people around you".

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Energy Level
"Having the mental, emotional and physical energy needed to perform tasks and activities"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Emotional Control

"Your ability to appropriately restrain or control your behavior when you experience strong feelings or emotions".

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Focus & Concentration
"Your ability to concentrate and immerse yourself in tasks and activities for a sustained period of time without getting distracted (sometimes called being in the zone, or flow)"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Appetite Regulation
"Your ability to consistently eat the quantity and type of foods needed to maintain a steady and healthy body weight"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Empathy
"Your ability to infer the mental and emotional state of other people, see things from their perspective, and respond appropriately

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Sensory Sensitivity
"Your ability to detect and respond appropriately to sounds, touch, smells, tastes or visual sensations in your environment

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Self-Image
"Your ability to have a positive perception of yourself and your body and a strong sense of your own identity

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Outlook & Optimism
"Your ability to have a hopeful and confident view of the future and to be positive in your attitude and approach

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Selective Attention
"Your ability to pick up on important information in your surroundings"

*

Is a real challenge and impacts my ability to function

1

2

3

4

5

6

7

8

9

It is a real asset to my life and my performance

Assess your: Restlessness & Hyperactivity
"The experience of being so fidgety or active that you are unable to relax or be still, even when it is required

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Fear & Anxiety
"Being scared or worried and experiencing feelings and sensations of, nervousness or panic in your mind or body"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Susceptibility to Infections
"The frequency with which you get colds, coughs, allergies or other types of infections"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Aggression Towards Others
"Displaying threatening, destructive or violent behavior towards others"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Avoidance & Withdrawal

"Having negative feelings that cause you to disengage from others or prevent you going to certain places"*

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Unwanted, Strange or Obsessive Thoughts

"Repetitive, strange or unpleasant thoughts that you can't stop thinking about or easily control".

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Mood Swings

"Switching quickly from one mood to another (e.g. happy to irritable) or experiencing extremes of different moods".

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Avoidance & Withdrawal

"Having negative feelings that cause you to disengage from others or prevent you going to certain places"*

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Sense of being detached from reality

"The sense that you are just observing your life, that your life is a dream or that you are not part of reality".

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Nightmares

"Having emotionally distressing dreams that wake you up during the night..

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Addictions

"Having a dependence you can’t control on something that has a negative impact on your health and wellbeing (e.g. substances, video games, gambling)"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Anger & Irritability

"Feeling or being angry, annoyed, frustrated or losing your temper when alone, or with those around you"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Suicidal Thoughts or Intentions
"Thinking or feeling like you want to kill or physically harm yourself

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Experience of Pain
"The experience of physical pain in your head or body."

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Guilt & Blame

"Experiencing thoughts or feelings that you are at fault or have done something wrong even when you are not responsible for the situation or event”

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Traumatic Flashbacks
"Experiencing emotionally distressing flashbacks or unwanted memories of negative experiences from the past".

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Hallucinations
"Hearing, seeing, feeling, smelling or tasting things that other people don't experience"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Feelings of Sadness, Distress or Hopelessness
"Experiencing overwhelming feelings of unhappiness, sorrow and hopelessness, or having spells of uncontrollable crying

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Physical Health Issues
"Having ongoing physical symptoms (e.g. digestive problems), or a chronic physical illness of any kind.

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Feelings of Sadness, Distress or Hopelessness
"Experiencing overwhelming feelings of unhappiness, sorrow and hopelessness, or having spells of uncontrollable crying

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

Assess your: Confusion or Slowed Thinking
"Having periods or episodes of feeling muddled and unclear in your mind and an inability to make sense of things"

*

Never cause me any problem

1

2

3

4

5

6

7

8

9

Has a constant and severe impact on my ability to function

In general, I get as much sleep as I need.
*

All of the time

Most of the time

Some of the time

Hardly ever

How regularly to you engage in physical exercise (30 minutes or more)? .
*

Every day

Few days a week

Once a week

Less than once a week

How regularly do you socialize with friends in person? .
*

Several days a week

Once a week

1-3 times a month

Rarely/Never

How regularly do you socialize with friends in person? .
*

Several days a week

Once a week

1-3 times a month

Rarely/Never

How many close friends do you have?
*

How many of your close friends have you known since early childhood (before age 12)*

*

Do any of your close friends live nearby (within an hour)?

*

Yes

No

What best describes the way you interact with your close friends?

*

I text with them every day or almost every day

I call on the phone or video just to chat or talk

I make time to visit them as often as possible

I plan trips and events to meet up with them

I find it difficult to make time or plans to meet in person

None of the above

Do you have friends who would help you out when you are sick or have a problem (e.g. bring food, watch kids)

*

Yes

No

Not sure

Prefer not to say

Do you have friends you can confide in and with whom you can express your true feelings and opinions?

*

Yes

No

Not sure

Prefer not to say

What was the nature of your household growing up?

*

Unstable and conflct

1

2

3

4

5

Stable and supportive

What was the nature of your household growing up?

*

Emotionally distant

1

2

3

4

5

Warm and caring

How did your parents or caregivers support you?

*

They provided everything I needed materially

They were supportive of my choices

They were very invested in my academic and other accomplishments

They always made time for me

None of the above

Prefer not to say

Required

How would you describe your relationships with your adult family?

*

I don’t have any family

I don’t get along with most of them and prefer not to see them often

I get along OK with them but we are not close

I am very close to some of them but not all

I am very close to many of my family members

Prefer not to say

Required

Please select which substances you consume regularly (at least every week) Select all that apply

*

Tobacco products (e.g. cigarettes, chewing tobacco, cigars, etc.)

Vaping products

Alcoholic beverages (e.g. beer, wine, spirits, etc.)

Cannabis (e.g. marijuana, pot, grass, hash, etc.)

Cocaine (e.g. coke, crack, etc.)

Amphetamine type stimulants (e.g. speed, diet pills, ecstasy, etc.)

Inhalants (e.g. nitrous, glue, petrol, paint thinner, etc.)

Sedatives or Sleeping Pills (e.g. Benzodiazepines, Valium, Serepax, Rohypnol, etc.)

Hallucinogens (e.g. LSD, acid, mushrooms, PCP, Special K, etc.)

Opioids (e.g. heroin, morphine, methadone, codeine, etc.)

Barbiturates (e.g. Nembutal, Pentobarbital)

None of the above

Prefer not to say

Others

Required

Is there any medical disorder that you have been diagnosed with
*

Yes

No

IF yes, mention the name

In the last year, have you seen a psychiatrist or mental health professional about any mental health concerns?
*

Yes

No

You answered "No" to the previous question. Please explain further by selecting the following:(Select all that apply)
*

No need for any mental health services

Can’t afford it / Not covered by health insurance

Don’t know where to go for services

Don’t know what kind of help to seek out

Don’t want other people to know/find out

No services near where I live

Don’t think it will help

Don’t have time

Think I can handle my difficulties without treatment

Worried I might be committed or forced to take medications

Some other reason

Prefer not to say

Required

Did you experience any of the following during your childhood (before age 18)?
*

Life threatening or debilitating injury or illness.

Sudden or premature death of a parent or sibling

Parental Divorce or family breakup

Prolonged physical abuse, or severe physical assault.

Prolonged sexual abuse, or severe sexual assault.

Physical violence in the home between family members (e.g. between parents)

Cyberbullying or online abuse

Prolonged or sustained bullying in person from peers

Prolonged emotional or psychological abuse or neglect from parent/caregiver

Lived with a parent/caregiver who was an alcoholic or who regularly used street drugs

Extreme poverty leading to homelessness and/or hunger.

Involvement or close witness to a war

Displacement from your home due to political, environmental or economic reasons

Serious injury, harm, or death you caused to someone else

Suffered a loss in a major fire, flood, earthquake, or natural disaster

Threatening, coercive or controlling behavior by another person

Forced family control over major life decisions (e.g. marriage)

Caring for a parent or sibling with a major chronic disability or illness

Parent/Caregiver/Sibling with mental illness or who committed suicide

Parent/Caregiver/Sibling went to prison

I did not experience any of the above during my childhood

Prefer not to say

Required

Have you experienced any of the following during your adult life (since age 18) Select all that apply
*

Sudden or premature death of a loved one.

Life threatening or debilitating injury or illness.

Divorce/separation or family breakup

Prolonged physical abuse, or severe physical assault.

Prolonged sexual abuse, or severe sexual assault.

Cyberbullying or online abuse

Extreme poverty leading to homelessness and/or hunger.

Involvement or close witness to a warSuffered a loss in a major fire, flood, earthquake, or natural disaster

Displacement from your home due to political, environmental or economic reasons

Loss of your job or livelihood leading to an inability to make ends meet.

Serious injury, harm, or death you caused to someone else

Caring for a child or partner with a major chronic disability or illness

Threatening, coercive or controlling behavior by another person

Forced family control over major life decisions (e.g. marriage)

I did not experience any of the above

Prefer not to say

Required

Over the last 2 weeks, how often have you been
bothered by Feeling down, depressed, or hopeless?T
*

Not at all

Several days

More than half a day

Nearly every day

Over the last 2 weeks, how often have you been
bothered by Feeling tired or having little energy?
*

Not at all

Several days

More than half a day

Nearly every day

Over the last 2 weeks, how often have you been
bothered by Poor appetite or overeating?
*

Not at all

Several days

More than half a day

Nearly every day

Over the last 2 weeks, 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?
*

Not at all

Several days

More than half a day

Nearly every day

Over the last 2 weeks, how often have you been
bothered by Trouble concentrating on things, such as reading the newspaper or watching television?
*

Not at all

Several days

More than half a day

Nearly every day

Over the last 2 weeks, how 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?
*

Not at all

Several days

More than half a day

Nearly every day

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