Mantra
Care
in partnership with
Mental Health Assessment
Step
1
of
18
5%
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? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
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?
Relationship (Personal)
Relationship (Professional)
Career
Academics (Exam / Grades)
Financial
Health
Self-esteem (weight, height, color, race etc)
Family / Parents
Sleep issues
Work Stress
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Company Name Hidden
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Your Anxiety Score
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Mild Anxiety Text
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Moderate Anxiety Text
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Severe Anxiety Text
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Your Depression Score
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Low Depression Text
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Mild Depression Text
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Moderate Depression Text
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Severe Depression Text
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Your Stress Score
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Low Stress Text
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Mild Stress Text
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Moderate Stress Text
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Severe Stress Text
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Overall Mental Health
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Low Overall Text
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Mild Overall Text
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Moderate Overall Text
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Severe Overall Text
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Phone
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No. of employees
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No. of employees for wellness program
0 – 250
251 – 500
501 – 1500
1501 – 10000
10001+
Name
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