Mental Health Questionnaire – with Becks Index

Personal Details

Full Name(Required)

Date of birth(Required)

Phone

General

I feel very stressed or anxious(Required)

Never

Sometimes

Often

Always

I feel unhappy/low/depressed(Required)

Never

Sometimes

Often

Always

I feel overwhelmed(Required)

Never

Sometimes

Often

Always

I am more irritable with those close to me(Required)

Never

Sometimes

Often

Always

I have thought that life is not worth living(Required)

Never

Sometimes

Often

Always

I am troubled by traumatic experiences(Required)

Never

Sometimes

Often

Always

I’ve had mental health problems in the past(Required)

Never

Sometimes

Often

Always

Sleep

I have difficulty getting a good night's sleep(Required)

Never

Sometimes

Often

Always

I lie awake for hours, my brain won't switch off(Required)

Never

Sometimes

Often

Always

I toss and turn all night(Required)

Never

Sometimes

Often

Always

I wake too early(Required)

Never

Sometimes

Often

Always

Diet & Lifestyle

My diet could be healthier(Required)

Never

Sometimes

Often

Always

I eat junk when feeling low or as a reward(Required)

Never

Sometimes

Often

Always

I feel guilty after eating junk(Required)

Never

Sometimes

Often

Always

I vomit after overeating(Required)

Never

Sometimes

Often

Always

I drink too much coffee/tea(Required)

Never

Sometimes

Often

Always

I drink sugary/energy drinks(Required)

Never

Sometimes

Often

Always

I may be overweight(Required)

Never

Sometimes

Often

Always

I am not getting enough exercise(Required)

Never

Sometimes

Often

Always

I feel unmotivated to improve my lifestyle(Required)

Never

Sometimes

Often

Always

I don't have energy to improve my lifestyle(Required)

Never

Sometimes

Often

Always

Unhelpful Habits

I feel I should cut down on my alcohol intake(Required)

Never

Sometimes

Often

Always

I use alcohol to self-medicate(Required)

Never

Sometimes

Often

Always

I drink alcohol alone(Required)

Never

Sometimes

Often

Always

I would find it difficult to skip alcohol for 5 nights(Required)

Never

Sometimes

Often

Always

I misuse drugs (Illegal or prescription(Required)

Never

Sometimes

Often

Always

I use drugs to self-medicate(Required)

Never

Sometimes

Often

Always

I feel I should cut down on my drug usage(Required)

Never

Sometimes

Often

Always

I have a problem with gambling(Required)

Never

Sometimes

Often

Always

Work Related

I have a lot of work stress(Required)

Never

Sometimes

Often

Always

I encounter bullying at work(Required)

Never

Sometimes

Often

Always

I am under financial stress(Required)

Never

Sometimes

Often

Always

I am unsure of my future career(Required)

Never

Sometimes

Often

Always

I have difficulty concentrating/remembering(Required)

Never

Sometimes

Often

Always

My work/life balance is not good(Required)

Never

Sometimes

Often

Always

I am juggling too many commitments(Required)

Never

Sometimes

Often

Always

Relationships & Family

I have difficulties with my partner(Required)

Never

Sometimes

Often

Always

I am single and unhappy about it(Required)

Never

Sometimes

Often

Always

I have some sexual concerns(Required)

Never

Sometimes

Often

Always

I have pregnancy/fertility concerns(Required)

Never

Sometimes

Often

Always

I have conflict with my family(Required)

Never

Sometimes

Often

Always

I had a troubled childhood(Required)

Never

Sometimes

Often

Always

I don't feel safe or secure(Required)

Never

Sometimes

Often

Always

I am avoiding friends and events(Required)

Never

Sometimes

Often

Always

I have lost contact with friends or family(Required)

Never

Sometimes

Often

Always

Pandemic Stress

My mental health is worse now than pre-pandemic(Required)

Never

Sometimes

Often

Always

I feel more isolated than before Covid(Required)

Never

Sometimes

Often

Always

I have more health anxiety now than before Covid(Required)

Never

Sometimes

Often

Always

Social Media & Screentime

I spend too much time on my phone*(Required)

Never

Sometimes

Often

Always

*You can check your phone and app usage on your handset. Go to Settings – Digital Balance/Digital Wellbeing. Most phones will allow you to set time limits on your App usage which you may find useful if you are trying to control the amount of time you spend on your phone or online.

I feel edgy if I am away from my phone(Required)

Never

Sometimes

Often

Always

I feel inadequate after reading about others online(Required)

Never

Sometimes

Often

Always

I spend too much time watching TV or gaming(Required)

Never

Sometimes

Often

Always

My tech use causes conflict with others(Required)

Never

Sometimes

Often

Always

I favour screentime over hobbies or exercise(Required)

Never

Sometimes

Often

Always

Any other mental health concerns not covered above?

Give brief details

Beck Anxiety Inventory

.

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by ticking the number that best corresponds to how each symptom has affected you.

0 = Not at all 1 = Mildly but it didn't bother me 2 = Moderately unpleasant 3 = Severely

Numbness or tingling(Required)

Feeling hot(Required)

Wobbliness in legs(Required)

Unable to relax(Required)

Fear of worst happening(Required)

Dizzy or lightheaded(Required)

Heart pounding/racing(Required)

Unsteady(Required)

Terrified or afraid(Required)

Nervous(Required)

Feeling of choking(Required)

Hands trembling(Required)

Shaky / unsteady(Required)

Fear of losing control(Required)

Difficulty in breathing(Required)

Fear of dying(Required)

Indigestion(Required)

Scared(Required)

Faint or Lightheaded(Required)

Face flushed(Required)

Hot/cold sweats(Required)

Scoring(Required)

Sum each column. Then sum the column totals to achieve a grand score. Enter that score here.

Add up your score and select below:

0 - 21

22 - 35

More than 36

A score between 0 and 21...

Indicates very low anxiety. That is usually a good thing. However, it is possible that you might be unrealistic in either your assessment which would be denial or that you have learned to “mask” the symptoms commonly associated with anxiety. Too little “anxiety” could indicate that you are detached from yourself, others, or your environment.

A score between 22 - 35...

Indicates moderate anxiety. Your body is trying to tell you something. Look for patterns as to when and why you experience the symptoms described above. For example, if it occurs prior to public speaking and your job requires a lot of presentations you may want to find ways to calm yourself before speaking or let others do some of the presentations. You may have some conflict issues that need to be resolved. Clearly, it is not “panic” time, but you want to find ways to manage the stress you feel.

A score over 36...

Indicates potential cause for concern. Again, look for patterns or times when you tend to feel the symptoms you have circled. Persistent and high anxiety is not a sign of personal weakness or failure. It is, however, something that needs to be proactively treated or there could be significant impacts to you mentally and physically. You may want to consult a physician or counsellor if the feelings persist.

Beck's Depression Inventory

.

This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire.

Question 1(Required)

0. I do not feel sad

1. I feel sad

2. I am sad all the time and I can't snap out of it.

3. I am so sad and unhappy that I can't stand it

Question 2(Required)

0. I am not particularly discouraged about the future.

1. I feel discouraged about the future.

2. I feel I have nothing to look forward to.

3. I feel the future is hopeless and that things cannot improve.

Question 3(Required)

0. I do not feel like a failure.

1. I feel I have failed more than the average person.

2. As I look back on my life, all I can see is a lot of failures

3. I feel I am a complete failure as a person.

Question 4(Required)

0.I get as much satisfaction out of things as I used to.

1. I don't enjoy things the way I used to.

2. I don't get real satisfaction out of anything anymore.

3. I am dissatisfied or bored with everything.

Question 5(Required)

0. I don't feel particularly guilty

1. I feel guilty a good part of the time.

2. I feel quite guilty most of the time.

3. I feel guilty all of the time.

Question 6(Required)

0. I don't feel I am being punished.

1. I feel I may be punished.

2. I expect to be punished.

3. I feel I am being punished.

Question 7(Required)

0. I don't feel disappointed in myself.

1. I am disappointed in myself.

2. I am disgusted with myself.

3. I hate myself.

Question 8(Required)

0. I don't feel I am any worse than anybody else.

1. I am critical of myself for my weaknesses or mistakes.

2. I blame myself all the time for my faults.

3. I blame myself for everything bad that happens.

Question 9(Required)

0. I don't have any thoughts of killing myself.

1. I think about killing myself, but I would not carry them out.

2. I would like to kill myself.

3. I would kill myself if I had the chance.

Question 10(Required)

0. I don't cry any more than usual.

1. I cry more now than I used to.

2. I cry all the time now.

3. I used to cry, but now I can't cry even though I want to.

Question 11(Required)

0. I am no more irritated by things than I ever was.

1. I am slightly more irritated now than usual.

2. I am quite annoyed or irritated a good deal of the time.

3. I feel irritated all the time.

Question 12(Required)

0. I have not lost interest in other people.

1. I am less interested in other people than I used to be.

2. I have lost most of my interest in other people.

3. I have lost all of my interest in other people.

Question 13(Required)

0. I make decisions about as well as I ever could.

1. I put off making decisions more than I used to.

2. I have more difficulty making decisions than I used to.

3. I can't make decisions at all anymore.

Question 14(Required)

0. I don't feel that I look any worse than I used to.

1. I am worried that I am looking old or unattractive

2. I feel there are permanent changes in my appearance that make me look unattractive

3. I believe that I look ugly.

Question 15(Required)

0. I can work about as well as before.

1. It takes an extra effort to get started at doing something.

2. I have to push myself very hard to do anything.

3. I can't do any work at all.

Question 16(Required)

0. I can sleep as well as usual.

1. I don't sleep as well as I used to.

2. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.

3. I wake up several hours earlier than I used to and cannot get back to sleep.

Question 17(Required)

0. I don't get more tired than usual.

1. I get tired more easily than I used to.

2. I get tired from doing almost anything

3. I am too tired to do anything.

Question 18(Required)

0. My appetite is no worse than usual.

1. My appetite is not as good as it used to be.

2. My appetite is much worse now.

3. I have no appetite at all anymore.

Question 19(Required)

0. I haven't lost much weight, if any, lately.

1. I have lost more than five pounds.

2. I have lost more than ten pounds.

3. I have lost more than fifteen pounds.

Question 20(Required)

0. I am no more worried about my health than usual.

1. I am worried about physical problems like aches, pains, upset stomach, or constipation.

2. I am very worried about physical problems and it's hard to think of much else

3. I am so worried about my physical problems that I cannot think of anything else.

Question 21(Required)

0. I have not noticed any recent change in my interest in sex.

1. I am less interested in sex than I used to be.

2. I have almost no interest in sex.

3. I have almost no interest in sex.

Scoring

Now that you have completed the questionnaire, add up the score for each of the twenty-one questions by counting the number to the right of each question you marked.

Levels of Depression

Score: 1 to 10

These ups and downs are considered normal

Score: 11 to 16

Mild mood disturbance

Score: 17 to 20

Borderline clinical depression

Score: 21 to 30

Moderate depression

Score: 31 to 40

Severe depression

Score: Over 40

Extreme depression

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(091) 530054

info@GalwayBayMedicalCentre.ie

Mental Health Questionnaire – with Becks Index

.

A score between 0 and 21...

A score between 22 - 35...

A score over 36...

.

Scoring

Score: 1 to 10

Score: 11 to 16

Score: 17 to 20

Score: 21 to 30

Score: 31 to 40

Score: Over 40

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