Assessment
Step
1
of
28
3%
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious or on edge?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Not being able to stop or control worrying?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Trouble relaxing?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Being so restless that it is hard to sit still?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Becoming easily annoyed or irritable?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Feeling afraid as if something awful might happen?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Little interest or pleasure in doing things?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Feeling down, depressed, or hopeless?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Trouble falling or staying asleep, or sleeping too much?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Feeling tired or having little energy?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Poor appetite or overeating?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Trouble concentrating on things, such as reading the newspaper or watching television?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Moving or speaking so slowly that other people could have noticed?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Thoughts that you would be better off dead, or of hurting yourself in some way?
Not At All
Several Days
More Than Half the days
Nearly Everyday
Feeling Stressed, burdened or hassled?
Not At All
Several Days
More Than Half the days
Nearly Everyday
What are the key reasons for your stress/ anxiety?
Relationships
Family
Health
Financial
Work
Job Security
Physical Wellbeing
Gender
Male
Female
Your Age
Weight (Kgs)
Height (ft)
Height (in)
How long do you exercise in a day?
How long do you exercise in a day?
No activity/ Desk job
Exercise 1-3 times/week
Exercise 4-5 times/week
Exercise 6-7 times/week
Do you have any known health conditions?
None
Diabetes
PCOS
Hypertension
Physical Pain(Back/ Neck / Knee)
Thyroid
Cholesterol
Heart Disease
Any family member suffering from these conditions?
None
Diabetes
PCOS
Hypertension
Physical Pain(Back/ Neck / Knee)
Thyroid
Cholesterol
Heart Disease
Do you experience any of these things?
None
Pee a lot
Always Thirsty
Always Hungry
Feel very tired
Sudden Lose of weight
Blurry vision
How often do you smoke in a day?
Don’t smoke at all
Less than 5
Between 5 to 10
More than 10
How many drinks do you have in a week?
Don’t drink at all
Less than 5
Between 5 to 10
More than 10
How many hours do you Sleep daily?
Less than 4 hours
4 to 6 hours
6 to 8 hours
More than 8 hours
How often do you face difficulty sleeping?
Not at all
Several Days
Nearly Everyday
Do you feel the need for a Wellbeing program (Therapy, Yoga, Physio, Dietician) for employees?
Yes
No
All done! Enter the following details to get the result (your details will be kept confidential)
Name
Email
Company Name
Hidden
Company Name Hidden
Phone
Hidden
Your Anxiety Score
Hidden
Low Anxiety Text
Hidden
Mild Anxiety Text
Hidden
Moderate Anxiety Text
Hidden
Severe Anxiety Text
Hidden
Your Depression Score
Hidden
Low Depression Text
Hidden
Mild Depression Text
Hidden
Moderate Depression Text
Hidden
Severe Depression Text
Hidden
Your Stress Score
Hidden
Low Stress Text
Hidden
Mild StressText
Hidden
Moderate Stress Text
Hidden
Severe Stress Text
Hidden
Overall Mental Health
Hidden
Low Overall Text
Hidden
Mild Overall Text
Hidden
Moderate Overall Text
Hidden
Severe Overall Text
Hidden
BMI
Hidden
Underweight BMI Text
Hidden
Overweight BMI Text
Hidden
Normal BMI Text
Hidden
BMR
Hidden
Diabetes
Hidden
Low Diabetes Text
Hidden
Mild Diabetes Text
Hidden
High Diabetes Text
Hidden
Sleep
Hidden
Medium Sleep Text
Hidden
High Sleep Text
Hidden
hypertension
Hidden
Low Hypertension Risk Text
Hidden
High Hypertension Risk Text
Hidden
physical
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Phone
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No. of employees
*
No. of employees for wellness program
0 – 250
251 – 500
501 – 1500
1501 – 10000
10001+
Name
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