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Questionnaire template

Mental Health and Wellbeing

Measures self-rated mental health, recent symptoms, stress sources, coping and support use among community or workforce members.

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Questions in this template

How You Are Doing

  1. Thank you for taking about ten minutes to tell us how you are doing. Your honest answers help us offer the right kind of support. If you need urgent help, please contact a health professional or a local crisis line.

  2. How would you describe your mental health at the moment?

    Choose one:

    • Excellent
    • Good
    • Fair
    • Poor
    • Very poor

  3. During the past two weeks, how often have you experienced each of the following?

    • Losing interest in things you usually enjoy
    • Feeling low or without hope
    • Problems with sleep, either too little or too much
    • Feeling worn out or short of energy
    • Eating much less or much more than usual

    For each row: choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always

  4. How often do you feel stressed?

    Choose one from a list:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always

  5. Which of these have you dealt with during the past month? Select all that apply.

    Choose any that apply:

    • Anxiety
    • Low mood or depression
    • Stress
    • Problems with alcohol or drugs
    • None of these

  6. If you would like to, tell us a little more about what you have been dealing with. (optional)

    Condition: Shown when at least one challenge was selected

    Open answer

Where Stress Comes From

  1. What are the main causes of stress in your life? Select all that apply.

    Choose any that apply:

    • Work
    • Family
    • Money
    • Health
    • Relationships
    • Other
    • None of these

  2. What else causes you stress?

    Condition: Shown when Other is selected

    Open answer

  3. How much does each of these areas affect your stress level?

    • Work
    • Relationships
    • Money
    • Health
    • Family responsibilities

    For each row: choose one:

    • No effect
    • A slight effect
    • A moderate effect
    • A strong effect
    • A very strong effect

Coping

  1. How often do you do things that help you relax?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always

  2. How well do the ways you currently cope help you manage stress?

    Choose one:

    • Very ineffective
    • Ineffective
    • Neither effective nor ineffective
    • Effective
    • Very effective

  3. What makes it hard to cope at the moment? (optional)

    Condition: Shown when coping is rated ineffective

    Open answer

Getting Support

  1. In the past year, have you seen a professional about your mental health?

    Choose one:

    • Yes
    • No

  2. What kind of professional help did you use? Select all that apply.

    Condition: Only for those who sought professional help

    Choose any that apply:

    • Therapist or counsellor
    • Psychiatrist
    • Support group
    • Online therapy
    • Other

  3. What other kind of help did you use?

    Condition: Shown when Other is selected

    Open answer

  4. How satisfied are you with the mental health support available to you?

    Choose one:

    • Very dissatisfied
    • Dissatisfied
    • Neither satisfied nor dissatisfied
    • Satisfied
    • Very satisfied

  5. What other resources or support would help you look after your mental health? (optional)

    Open answer