Mental Wellbeing Assessment Form

Mental Wellbeing Assessment Form

Please complete this form to evaluate and identify key aspects of an individual’s mental wellbeing.

Full Name

    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

    1. Feeling nervous, anxious, or on edge

    1. Not being able to stop or control

    1. Worrying too much about different things

    1. Trouble relaxing

    1. Being so restless that it is hard to sit still

    1. Becoming easily annoyed or irritable

    1. 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

    1. Little interest or pleasure in doing things

    1. Feeling down, depressed, or hopeless

    1. Trouble falling or staying asleep, or sleeping too much

    1. Feeling tired or having little energy

    1. Poor appetite or overeating

    1. Feeling bad about yourself- or that you are a failure or have let yourself or your family down

    1. Trouble concentrating on things, such as reading the newspaper or watching television

    1. 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. Thoughts that you would have be better off dead

    Additional information if you need:

    Assessment Form Template @ Template.net

    Thank you for submission!

    We appreciate you taking the time to submit.

    Create free forms at Template.net