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Questionnaire template

Mental Wellbeing Self-Reflection

A non-diagnostic self-reflection for adults on recent mood, stress, coping, daily functioning and support.

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Questions in this template

Mood and Energy

  1. This short self-reflection helps you take stock of how you have been feeling over the past two weeks. It is not a diagnosis; if you are concerned about your mental health, please talk to a doctor or another qualified professional.

  2. If you are in crisis or thinking about harming yourself, please contact your local emergency number or a crisis helpline now.

  3. Over the past two weeks, how would you describe your mood overall?

    Choose one:

    • Very good
    • Good
    • Fair
    • Poor
    • Very poor

  4. Over the past two weeks, how often have you felt...

    • Calm
    • Hopeful about the future
    • Low or down
    • Worried or on edge
    • Easily annoyed

    For each row: choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Almost always

  5. How well have you been sleeping?

    Choose one:

    • Very good
    • Good
    • Fair
    • Poor
    • Very poor

  6. On a typical day recently, how much energy have you had?

    A number from 0 to 10

Stress and Coping

  1. How stressed have you felt over the past two weeks?

    A number from 0 to 10

  2. What has been causing you stress? Select all that apply.

    Choose any that apply:

    • Work or studies
    • Money
    • Relationships
    • Physical health
    • Caring for others
    • Housing
    • Something else
    • Nothing in particular

  3. What else has been causing you stress?

    Condition: Shown when 'Something else' was selected

    Open answer

  4. What have you done to cope when things felt difficult? Select all that apply.

    Choose any that apply:

    • Physical activity
    • Talking to someone
    • Spending time outdoors
    • Hobbies
    • Resting
    • Relaxation or mindfulness
    • Alcohol or other substances
    • None of these

  5. How well have these ways of coping worked for you?

    Condition: Shown when at least one way of coping was selected

    Choose one:

    • Very well
    • Fairly well
    • Not very well
    • Not at all

Daily Life and Connection

  1. Over the past two weeks, how much have your feelings got in the way of...

    • Work or studies
    • Household tasks
    • Seeing friends and family
    • Looking after your physical health

    For each row: choose one:

    • Not at all
    • A little
    • Moderately
    • A lot

  2. How connected do you feel to the people around you?

    Choose one:

    • Very connected
    • Somewhat connected
    • A little connected
    • Not at all connected

  3. Is there someone you can talk to openly when you are struggling?

    Choose one:

    • Yes
    • No
    • Not sure

Support

  1. In the past 12 months, have you looked for professional help with your mental health?

    Choose one:

    • Yes
    • No

  2. Where did you get help? Select all that apply.

    Condition: Shown to those who looked for help

    Choose any that apply:

    • Family doctor
    • Counsellor or therapist
    • Psychiatrist
    • Helpline
    • Peer support group
    • Other

  3. What, if anything, has stopped you from looking for help? Select all that apply.

    Condition: Shown to those who did not look for help

    Choose any that apply:

    • I did not feel I needed it
    • Cost
    • Not knowing where to go
    • Waiting times
    • Worry about what others would think
    • Something else

  4. What is one thing you would like to change to look after your wellbeing better? (optional)

    Open answer