Mental Health Questionnaire

Patient Name

First Name Last Name

Today's Date

Date

In the last two weeks, how often have you been bothered by:

Feeling nervous, anxious or on edge?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Not being able to stop or control worrying?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Worrying too much about different things?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Trouble relaxing?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Being so restless that it's hard to sit still?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Becoming easily annoyed or irritable?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Feeling afraid as if something awful might happen?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Little interest or pleasure in doing things?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Feeling down, depressed, or hopeless?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Trouble falling or staying asleep, or sleeping too much?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Feeling tired or having little energy?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Poor appetite or overeating?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Feeling bad about yourself — or that you are a failure or have let yourself or your family down?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

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

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Not at all. 0 Several days. 1 More than half the days. 2 Most of the days. 3

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