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Questionnaire template

Emotional Distress Self-Reflection

Non-diagnostic reflection for adults on how often they feel distressed, how they cope and which areas of life are affected.

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Healthcare · Mental health assessment. All Healthcare templates

Questions in this template

Experiencing Distress

  1. Thank you for taking part. These questions help you reflect on emotional distress and how it affects you; they are not a diagnosis. If you feel unsafe or overwhelmed, please contact a health professional or a local crisis line.

  2. How often do you feel emotionally distressed?

    Choose one:

    • Never
    • Rarely
    • Occasionally
    • Frequently
    • Constantly

  3. When you feel distressed, what do you notice in your emotions and in your body?

    Condition: Shown to people who feel distressed at least rarely

    Open answer

  4. How intense is your distress on a typical occasion?

    Condition: Shown to people who feel distressed at least rarely

    Choose one:

    • Not at all distressing
    • Slightly distressing
    • Moderately distressing
    • Very distressing
    • Extremely distressing

Coping

  1. Do you have ways of dealing with distress when it comes?

    Choose one:

    • Yes
    • No
    • Unsure

  2. What do you do when you feel distressed, and how well does it work?

    Condition: Shown to people who have ways of coping

    Open answer

  3. How helpful are these approaches for you?

    • Breathing or relaxation exercises
    • Physical activity
    • Support from people close to you
    • Professional help

    For each row: choose one:

    • Not at all helpful
    • Slightly helpful
    • Moderately helpful
    • Very helpful
    • Extremely helpful
    • Have not tried

Effects on Daily Life

  1. Which parts of your life does distress affect most? Select all that apply.

    Choose any that apply:

    • Work or study
    • Relationships
    • Physical health
    • Mental wellbeing
    • Hobbies and interests
    • None of these

  2. Compared with a year ago, has the amount of distress in your life changed?

    Choose one:

    • Increased
    • Stayed about the same
    • Decreased