Emotional and Mental Health Assessment

No.	Question	Choose Most Appropriate Answer
1	Little interest or joy in hobbies or activities?	No problem with interest in hobbies / activities Lost interest in hobbies / activities: in 2 - 3 days per week Lost interest in hobbies / activities: in 4 - 5 days per week Lost interest in hobbies / activities: almost Every day
2	Sad, down, or hopeless?	No problem of sad feelings Sad feelings: in 2 - 3 days per week Sad feelings: in 4 - 5 days per week Sad feelings: almost Every day
3	Trouble sleeping? or sleeping too much?	No problem with sleep Sleep trouble or excess: in 2 - 3 days per week Sleep trouble or excess: in 4 - 5 days per week Sleep trouble or excess: almost Every day
4	Tired or low on energy?	No problem of low energy Low energy: in 2 - 3 days per week Low energy: in 4 - 5 days per week Low energy: almost Every day
5	Eating much less? or more than usual?	No problem with eating Less or excess eating: in 2 - 3 days per week Less or excess eating: in 4 - 5 days per week Less or excess eating: almost Every day
6	Bad about yourself, like a failure?	No problem with self-esteem Bad self-esteem: in 2 - 3 days per week Bad self-esteem: in 4 - 5 days per week Bad self-esteem: almost Every day
7	Hard to focus on reading or TV?	No problem with focus / concentration Low focus / concentration: in 2 - 3 days per week Low focus / concentration: in 4 - 5 days per week Low focus / concentration: almost Every day
8	Moving / speaking slowly? or very restless?	No problem with movement or speech Slow or hectic movement or speech: in 2 - 3 days per week Slow or hectic movement or speech: in 4 - 5 days per week Slow or hectic movement or speech: almost Every day
9	Thoughts of not wanting to live or self-harm?	No self-harm thoughts Self-harm thoughts: in 2 - 3 days per week Self-harm thoughts: in 4 - 5 days per week Self-harm thoughts: almost Every day
10	How hard is work, home, or socializing?	No difficulty in work, home, or socializing Low difficulty in work, home, or socializing High difficulty in work, home, or socializing Very High difficulty in work, home, or socializing
11	So good "hyper" caused trouble?	No, didn't happen to be so good "hyper" causing trouble So good "hyper" causing trouble: Yes, happened
12	Very irritable, shouting, or starting fights?	No, didn't happen to be very irritable, shouting, or starting fights Very irritable, shouting, or starting fights: Yes, happened
13	Much more confident than usual?	No, didn't happen to be much more confident than usual Much more confident than usual: Yes, happened
14	Needed less sleep and felt fine?	No, didn't happen to need less sleep with feelling fine Needed less sleep and felt fine: Yes, happened
15	Extra talkative or speaking fast?	No, didn't happen to be extra talkative or speaking fast Extra talkative or speaking fast: Yes, happened
16	Racing thoughts, mind won't slow?	No, didn't happen to have racing thoughts with restless mind Racing thoughts, mind won't slow: Yes, happened
17	Easily distracted, couldn't focus?	No, didn't happen to be easily distracted and couldn't focus Easily distracted, couldn't focus: Yes, happened
18	Had way more energy than usual?	No, didn't happen to have way more energy than usual Had way more energy than usual: Yes, happened
19	Did unusual, excessive, or risky things with painful consequences?	No, didn't happen to do unusual, excessive, or risky things with painful consequences Did unusual, excessive, or risky things with painful consequences: Yes, happened
20	Extra social, like calling / visiting friends at inappropriate times?	No, didn't happen to be extra social, like calling / visiting friends at inappropriate times Extra social, like calling / visiting friends at inappropriate times: Yes, happened
21	Spending caused trouble for you or for your family?	No, didn't happen that spending caused trouble for me or for my family Spending caused trouble for me or for my family: Yes, happened
22	Positive findings in questions 11-21 occurred at same times?	No, didn't happen that positive findings in questions 11-21 occurred at same times Positive findings in questions 11-21 occurred at same times: Yes, happened
23	Duration of positive findings in questions 11-21?	No positive findings in questions 11-21 Positive findings in questions 11-21: resolved / ended after 1 - 3 days Positive findings in questions 11-21: resolved / ended after 4 days or longer
24	Caused unusual recent problems (work, family, legal)?	No unusual recent problems caused in work, family, or legal Yes, only minor unusual recent problems caused in work, family, or legal Yes, moderate unusual recent problems caused in work, family, or legal Yes, serious unusual recent problems caused in work, family, or legal
25	Cold, hair loss, constipation, or dry skin?	No feeling cold, hair loss, constipation, or dry skin Yes for some, not for all of these: feeling cold, hair loss, constipation, and dry skin Yes for all: feeling cold, hair loss, constipation, and dry skin
26	New shortness of breath, paleness, or unusaual bleeding?	No, didn't happen to have new shortness of breath, paleness, or unusaual bleeding New shortness of breath, paleness, or unusaual bleeding: Yes, happened
27	Trouble focusing new or since childhood?	No troubles in focusing New troubles in focusing Since childhood troubles in focusing
28	Taking any medications for any complaint?	No, don't take any medications Yes, taking some medications
29	Loud snoring, stopped breathing, or daytime sleepiness?	No loud snoring, stopped breathing, or daytime sleepiness Yes for some, not for all of these: loud snoring, stopped breathing, and daytime sleepiness Yes for all: loud snoring, stopped breathing, and daytime sleepiness

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