Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Mental Health Check-in

A brief adult mental health check-in covering self-rated mental health, mood and anxiety screening, daily functioning and support.

Preview

Healthcare · Mental health. All Healthcare templates

Questions in this template

Overall Mental Health

  1. Thank you for taking a few minutes to check in on your mental health. Your answers are confidential and help us understand what support people need.

  2. If you are thinking about harming yourself or feel unsafe, please contact a health professional or a local crisis service right away.

  3. How would you rate your mental health at the moment?

    Choose one:

    • Excellent
    • Very good
    • Good
    • Fair
    • Poor

  4. Compared with a year ago, how is your mental health now?

    Choose one:

    • Much better
    • Somewhat better
    • About the same
    • Somewhat worse
    • Much worse

Mood and Anxiety

  1. The next questions are the Patient Health Questionnaire-2 (PHQ-2) and the Generalized Anxiety Disorder-2 (GAD-2, the first two items of the GAD-7), developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke and colleagues. They are free to use.

  2. These results are a screening aid, not a diagnosis. A health professional can help you interpret them.

  3. Over the last 2 weeks, how often have you been bothered by the following problems?

    • Little interest or pleasure in doing things
    • Feeling down, depressed, or hopeless

    For each row: choose one:

    • Not at all
    • Several days
    • More than half the days
    • Nearly every day

  4. Over the last 2 weeks, how often have you been bothered by the following problems?

    • Feeling nervous, anxious, or on edge
    • Not being able to stop or control worrying

    For each row: choose one:

    • Not at all
    • Several days
    • More than half the days
    • Nearly every day

Daily Life

  1. Over the past month, how would you rate the quality of your sleep?

    Choose one:

    • Very good
    • Fairly good
    • Fairly bad
    • Very bad

  2. Over the past month, how much difficulty have you had with each of these because of how you were feeling?

    • Keeping up with work, study or household tasks
    • Concentrating on what you are doing
    • Staying in touch with the people who matter to you

    For each row: choose one:

    • No difficulty
    • Some difficulty
    • A lot of difficulty
    • Could not do it at all

  3. During the past 30 days, on how many days did you feel your mental health was not good?

    A number from 0 to 30

Support

  1. Have you ever had professional help for your mental health, such as counselling, therapy or medication?

    Choose one:

    • Yes, currently
    • Yes, in the past
    • No, never

  2. Has anything made it harder for you to get mental health support?

    Choose any that apply:

    • Cost
    • Waiting times
    • Not knowing where to go
    • Worry about what others might think
    • Preferring to handle it myself
    • Nothing has made it harder

  3. What kind of support would help you most right now?

    Open answer