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Baseline Assessment
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Your Name:
Your answer
Your Mental Wellbeing
Over the last 2 weeks
I have felt cheerful & in good spirits
ALL of the time
MOST of the time
SOME of the time
at NO time
Other:
I have felt calm & relaxed
ALL of the time
MOST of the time
SOME of the time
at NO time
Clear selection
I have felt active & vigorous
ALL of the time
MOST of the time
SOME of the time
at NO time
Clear selection
I woke up feeling fresh & rested
ALL of the time
MOST of the time
SOME of the time
at NO time
Clear selection
My daily life has been filled with things that interest me
ALL of the time
MOST of the time
SOME of the time
at NO time
Clear selection
Your Physical Wellbeing
Thinking about the LAST WEEK how physically active have you been?
Least Physically Active
0
1
2
3
4
5
6
7
8
9
10
Most Physically Active
Clear selection
Your Social Connections
I am content with my friendships & relations
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Clear selection
I have enough people I feel comfortable asking for help at any time
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Clear selection
My relationships are as satisfying as I would want them to be
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Clear selection
Your Community
How often do you contact, see or use the GP, Nurse, 999, 111, Pharmacist or any other medical team?
Never
Hardly Ever
Sometimes
Often
Clear selection
How often do you join in with local clubs, groups & activities?
Never
Hardly Ever
Sometimes
Often
Clear selection
How often do you help someone local to you?
Never
Hardly Ever
Sometimes
Often
Clear selection
Measure of well-being
Next I would like to ask you four questions about your feelings on aspects of your life. There are no right or wrong answers. For each of these questions I’d like you to give an answer on a scale of 0 to 10, where 0 is ‘not at all’ and 10 is ‘completely’:
Overall, how satisfied are you with you life nowadays?
Not at all
0
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
Overall, to what extent do you feel that the things you do in your life are worthwhile?
Not at all
0
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
Overall, how happy did you feel yesterday?
Not at all
0
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
How anxious did you feel yesterday?
Not at all anxious
0
1
2
3
4
5
6
7
8
9
10
Completely anxious
Clear selection
With all this in mind, how do you want your life to change or stay the same?
Your answer
Next
Clear form
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