Contact Information
Would you kindly take a few minutes to complete this
survey about your general state of mental health?
We appreciate your input, and we won't share your
answers with anybody. I appreciate your thoughts.
12.
Very often
* Indicates required question
1.
Email *
2.
Name (ex. Pedro, Juan B.) *
3.
Email (ex. juanperdo123@gmail.com) *
4.
Address: *
5.
Phone number: (09123456789)
6.
Age: (19)
7.
During the past 4 weeks, how often has your mental
health affected your ability to get your studies done? *
Mark only one oval.
Somewhat often
Not so often
Not at all
13.
Have you felt particularly low or down for more than 2
weeks in a row? *
Mark only one oval.
Very often
Somewhat often
Not so often
Gender: *
Mark only one oval.
Female
Not at all
14.
Male
Prefer not to say
During the past two weeks, how often has your mental
health affected your relationships? *
Mark only one oval.
Very often
Other:
Somewhat often
Mental Health Questionnaires
Not so often
8.
Not at all
Overall, how would you rate your physical health? *
Mark only one oval.
Excellent
15.
Average
Have you noticed any change in your diet habits? *
Mark only one oval.
Yes, I eat too much
Somewhat poor
Yes, I don't feel hungry
Poor
Not much
Not sure
No change
9.
Overall, how would you rate your mental health? *
Mark only one oval.
Excellent
16.
Average
Few days ago
Somewhat poor
Few weeks ago
Poor
Few months ago
Not sure
10.
11.
During the past 4 weeks, have you had any problems
with your studies or daily life due to your physical
health? *
Mark only one oval.
Yes
When was the last time you were really happy? *
Mark only one oval.
Few years ago
I don't remember
17.
When was the last time you felt good about yourself? *
Mark only one oval.
No
Few days ago
Not Sure
Few weeks ago
During the past 4 weeks, have you had any problems
with your studies or daily life due to any emotional
problems, such as feeling depressed, sad or anxious?*
Mark only one oval.
Yes
No
Not Sure
Few months ago
Few years ago
I don't remember
18.
How often do you feel positive about your life? *
Mark only one oval.
24.
Never
If "Yes", please select which of the family member(s)
had a history of mental illness. *
Check all that apply.
Mother
Once in a while
Father
About half the time
Brother
Sister
Most of the time
Grandfather
Always
19.
How often do you feel positive about your life? *
Mark only one oval.
Grandmother
25.
Never
Yes
Once in a while
About half the time
Have you seen a therapist in the recent past? *
Mark only one oval.
No
26.
Are you currently taking any medication? *
Mark only one oval.
Most of the time
Yes
Always
20.
When was the last time you had a positive outlook on
life? *
Mark only one oval.
No
27.
Few days ago
Less than 4
Few weeks ago
4-6
Few months ago
7-9
Few years ago
I don't remember
21.
How many hours do you sleep per day? *
Mark only one oval.
9+
28.
Have you ever been diagnosed with a mental disorder
before? *
Mark only one oval.
How is your quality of sleep? *
Mark only one oval.
Very bad
Bad
Yes
Normal
No
Good
Not sure
Very good
22.
23.
When did you last get your mental health examination
done? *
Mark only one oval.
29.
What is your relationship status? *
Mark only one oval.
Less than 6 months ago
Single
6 months ago
Married
A year ago
Widowed
More than a year ago
Divorced
Never
Separated
Is there a history of mental disorder in your family? *
Mark only one oval.
30.
Do you feel content with your relationships and family?
*
Mark only one oval.
Yes
No
Not sure
Yes
Sometimes
No