Full Name
Date of Birth
Gender MaleFemaleOther
Email Address
Phone
How often do you feel stressed? Almost every dayA few times a weekOccasionallyRarely
How would you describe your current mood? Positive/optimisticNeutralAnxious or stressedDepressed or low
Have you experienced any of the following in the past 6 months?(Check all that apply): Persistent feelings of sadness or hopelessnessDifficulty concentrating or making decisionsFatigue or lack of energy despite adequate sleepSignificant changes in appetite or weightNone of the above Others
Do you have a support system (family, friends, or community) you can turn to in times of stress? Yes, alwaysYes, sometimesRarely or never
Have you been diagnosed with or sought help for any of the following? AnxietyDepressionBipolar disorderPost-traumatic stress disorder (PTSD)None of the above Others
How often do you take time for self-care (e.g., relaxation, hobbies, exercise)? DailyWeeklyRarely or never
How often do you exercise? DailyA few times a weekRarely or never
How many hours of sleep do you get per night? Less than 5 hours5-7 hoursMore than 7 hours
Do you have a balanced diet? Yes, alwaysSometimesRarely or never
Do you consume alcohol? Yes, regularlyOccasionallyRarely or never
Do you smoke? Yes, dailyOccasionallyNo
Have you been diagnosed with any of the following? High blood pressureDiabetesHigh cholesterolHeart diseaseAsthma or other respiratory conditionsNone of the above Others
Does your family have a history of the following? Mental health conditions (e.g., depression, anxiety)Heart diseaseDiabetesCancerNone of the above
Do you currently experience any of the following?(Check all that apply): Persistent fatigue or low energyDifficulty sleeping (insomnia or oversleeping)Chronic pain or discomfortLoss of interest in activities you previously enjoyedPersistent worry, fear, or panicNone of the above
Would you like to discuss or learn more about mental health support services? YesNo
