Mental Health Survey

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Mental Health Survey
Patient Name:
Date Completed:
Therapist Name:
Date Received:
Mood and Behaviors Over the Past 2 Weeks
Comments
1
I feel sad, unhappy or depressed
1
2
3
4
5
I feel lethargic, apathetic, or as though I have no energy
1
2
3
4
5
2
3
I feel hopeless about the future
1
2
3
4
5
4
I feel lonely, isolated or alone
1
2
3
4
5
5
I have trouble sleeping
1
2
3
4
5
6
I sleep too much
1
2
3
4
5
7
I have no appetite
1
2
3
4
5
8
I overeat
1
2
3
4
5
9
I feel unproductive or get distracted easily at work
1
2
3
4
5
10 I have trouble focusing on projects, work or activities
1
2
3
4
5
11 Activities and work no longer interest me
1
2
3
4
5
12 I have trouble getting along with family/friends/coworkers
1
2
3
4
5
13 I feel tense or nervous
1
2
3
4
5
14 I feel agitated, angry or irritable
1
2
3
4
5
15 I think about hurting myself
1
2
3
4
5
16 I consider suicide
1
2
3
4
5
17 I drink or do drugs to escape or dull the pain
1
2
3
4
5
18 I binge drink (more than 5 drinks in one hour)
1
2
3
4
5
19 People express concern about my drinking or drug use
1
2
3
4
5
20 I have had trouble at work or school due to alcohol/drugs
1
2
3
4
5

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