Mindset Score
This form was created by the Modern Mind Group to look at how you feel and provide you a score and give some guidance. It will cover mood levels, worries, work home and social life as well as phobias.

Please fill in as honestly as possible.

All of the information is kept private and confidential.
Over the last 2 weeks how often have you been having little interest or pleasure in doing things? *
Not at all
Nearly everyday
Over the last 2 weeks how often have you been feeling down depressed and hopeless? *
Not at all
Nearly Everyday
Over the last 2 weeks how often have you had trouble falling asleep, staying asleep or sleeping too much? *
Not At All
Nearly Every Day
Over the last 2 weeks, how often have you been feeling tired or have little energy? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you had a poor appetite or find yourself overeating? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you felt bad about yourself, that you are a failure or have let yourself down? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you had trouble concentrating on things such as reading the newspaper or watching television? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you been moving or speaking slowly that other people could notice or being fidgety or restless that you are moving around a lot more? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you had thoughts about hurting yourself or that you would be better off not being alive? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you been feeling nervous, anxious or on edge? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you not been able to stop or control worrying? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you been worrying too much about different things? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you had trouble relaxing? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you been so restless that it is hard to sit still? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you become easily annoyed, angry or irritable? *
Not At All
Nearly Every Day
Over the last 2 weeks how often have you been feeling afraid as if something might happen? *
Not At All
Nearly Every Day
How often do you avoid social situations because of fear of being embarrassed or making a fool of myself? *
Would Not Avoid
Always Avoid
How often do you avoid situations because of fear of a panic attack or other destressing symptoms such as loss of bladder control, vomiting or dizziness? *
Would Not Avoid
Always Avoid
How often do you avoid situations because of fear of particular objects and activities such as animals, heights, seeing blood, confined space, driving or flying? *
Would Not Avoid
Always Avoid
How much does the way you're feeling affect work life? (Select N/A if you are retired or not working) *
Not Affected (Also select this if not working or retired)
Severely Affected
How much does the way you're feeling affect home life? (cleaning tidying, shopping, cooking, looking after home/ children, paying the bills etc) *
Not Affected
Severely Affected
How much does the way you're feeling affect your personal hygiene? *
Not Affected
Severely Affected
How much does the way you feel affect your social activities? (with other people, parties, pubs, outings, entertaining) *
Not Affected
Severely Affected
How much does the way you feel affect private leisure activities reading, hobbies, gardening,sewing, walking ? (Done alone) *
Not Affected
Severely Affected
If I don't have enough time to do everything I worry about it *
Not at all like me
Very like me
My worries overwhelm me *
Not at all like me
Very like me
I always worry *
Not at all like me
Very like me
Many situations make me worry *
Not at all like me
Very like me
I know I should not worry but I can't help it *
Not at all like me
Very like me
When under pressure I worry a lot *
Not at all like me
Very like me
I find it difficult to dismiss worrying thoughts *
Not at all like me
Very like me
As soon as I finish one task I start to worry about everything else I have to do
Not at all like me
Very like me
Clear selection
When I know there is nothing more I can do about a concern I still continue to worry about it *
Not at all like me
Very like me
I notice that I have been worrying about things *
Not at all like me
Very like me
Once I start worrying I find it hard to stop *
Not at all like me
Very like me
I worry about projects or tasks until they are done *
Not at all like me
Very like me
What is your name? *
What is your email address? (this is so that we can send your response) *
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