Mental Health Systems check-in

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Depression rating? Rate yourself. ( Scale 1 - 10 )

1 is low feelings of depression. 10 is high levels of depression.

Anxiety rating? Rate yourself. ( Scale 1 - 10 )

1 is low feelings of anxiety. 10 is high levels of anxiety.

Name 3 of the biggest emotions you have experienced this week.

List 3 things you feel good about right now.

Do you consume large amounts of food without constraint ?

Maybe

Yes

Clear selection

Do you eat in reaction to stressful events ?

Yes

Maybe

Clear selection

Do you force yourself to vomit after eating?

Yes

Clear selection

Does your weight loss planning involve excessive exercise?

Yes

Clear selection

How often do you have trouble wrapping up the final details of a project. Once the challenging parts have been done?

Never

Occasionally

Sometimes

Often

Always

Other:

Clear selection

How often do you have difficulty getting things in order when you have to do a task that requires organization?

Never

Occasionally

Sometimes

Often

Always

Other:

Clear selection

How often do you have problems remembering obligations?

Never

Occasionally

Sometimes

Often

Always

Other:

Clear selection

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you feel overly active and compelled to do things. Like you were driven by a motor?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you make careless mistakes when you have to work on a boring or difficult project?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you have difficulty concentrating on what people say to you , even when they are speaking to you directly?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you misplace or have difficulty finding things at home or at school?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often are you distracted by activity or noise around you?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you feel restless or fidgety?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you have difficulty unwinding and relaxing when you have time to yourself?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you find yourself talking to much when you are in social situations?

Never

Occasionally

Sometimes

Often

Always

Other:

Clear selection

When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you have difficulty waiting your turn in situations when turn taking is required?

Never

Occasionally

Sometimes

Often

Always

Clear selection

How often do you interrupt others when they are busy?

Never

Occasionally

Sometimes

Often

Always

Other:

Clear selection

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