Mental Wellbeing Assessment Form
Please complete this form to evaluate and identify key aspects of an individual’s mental wellbeing.
Over the last 2 weeks, how often have you been bothered by the following problems?
| Not at All | Several Days | More than half the days | NearlyEveryday |
|---|
Feeling nervous, anxious, or on edge
| | | | |
Not being able to stop or control
| | | | |
Worrying too much about different things
| | | | |
Trouble relaxing
| | | | |
Being so restless that it is hard to sit still
| | | | |
Becoming easily annoyed or irritable
| | | | |
Feeling afraid as if something awful might happen
| | | | |
Over the last 2 weeks, how often have you been bothered by the following problems?
| Not at All | Several Days | More than half the days | Nearly
Every day |
|---|
Little interest or pleasure in doing things
| | | | |
Feeling down, depressed, or hopeless
| | | | |
Trouble falling or staying asleep, or sleeping too much
| | | | |
Feeling tired or having little energy
| | | | |
Poor appetite or overeating
| | | | |
Feeling bad about yourself- or that you are a failure or have let yourself or your family down
| | | | |
Trouble concentrating on things, such as reading the newspaper or watching television
| | | | |
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
| | | | |
Thoughts that you would have be better off dead
| | | | |
Assessment Form Template @ Template.net
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