Mental Health Awareness Survey

Name:
Age:
Address:

Gender:

Male Female

Q1)Do you face any difficulty in sleeping?

yes no

Q2)Are you facing extreme sadness or sorrow?

yes no

Q3)Are you feeling nervous,restless or tense?

yes no

Q4)Are you facing increased heartrates or sweaty or cold hands?

yes no

Q5)Are you feeling weak and tired all the time?

yes no

Q6)Are you frequently facing muscle tightness?

yes no

Q7)Do you have a lack of interest in social or personal relationships?

yes no

Q8)Do you consider yourself to have an unstable or fragile self image?

yes no

Q9)Do you frequently experience vivid memories about any traumatic event?

yes no

Q10)Are you experiencing disorganised speech,difficulty with concentration or memory?

yes no

Q11)Are you experiencing reduced interest in activites you once loved?

yes no

Q12)Are you experiencing shallow or rapidly changing emotions?

yes no

Q13)Are you experiencing any nightmares or hallucinations?

yes no

Q14)Do you often feel suspicious about others and sense a feeling of mistrust regularly?

yes no