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Emotional Health Survey

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Emotional Health Survey

Let’s start with your

Overall Emotional Wellbeing

START

Just a few more questions

Have you suffered from COVID ?
Yes No
Has any of your family members or friends suffered from COVID ?
Yes No
Has any one close to you passed away recently ?
Yes No

1 / 18

Compared to 12 weeks ago are you now

More worried about your finances ?

Extremely
A lot
Moderately
A little bit
Not at all

2 / 18

Compared to 12 weeks ago are you now

Generally more worried and anxious ?

Extremely
A lot
Moderately
A little bit
Not at all

3 / 18

Compared to 12 weeks ago are you now

Having more difficulty in concentrating ?

Extremely
A lot
Moderately
A little bit
Not at all

4 / 18

Compared to 12 weeks ago are you now

Being less productive ?

Extremely
A lot
Moderately
A little bit
Not at all

5 / 18

Compared to 12 weeks ago are you now

More worried about your personal health and safety ?

Extremely
A lot
Moderately
A little bit
Not at all

6 / 18

Compared to 12 weeks ago are you now

Being more bored ?

Extremely
A lot
Moderately
A little bit
Not at all

7 / 18

Compared to 12 weeks ago are you now

Having more difficulty sleeping or sleeping too much ?

Extremely
A lot
Moderately
A little bit
Not at all

8 / 18

Compared to 12 weeks ago are you now

Feeling more lonely or isolated ?

Extremely
A lot
Moderately
A little bit
Not at all

9 / 18

Compared to 12 weeks ago are you now

Feeling more down or depressed ?

Extremely
A lot
Moderately
A little bit
Not at all

10 / 18

Compared to 12 weeks ago are you now

More worried about the health and safety of family members or friends ?

Extremely
A lot
Moderately
A little bit
Not at all

11 / 18

Compared to 12 weeks ago are you now

Feeling more frustrated that you cannot enjoy what enjoyed before ?

Extremely
A lot
Moderately
A little bit
Not at all

12 / 18

Compared to 12 weeks ago are you now

More angry or irritated ?

Extremely
A lot
Moderately
A little bit
Not at all

13 / 18

Compared to 12 weeks ago are you now

Feeling that the future seems darker or scarier ?

Extremely
A lot
Moderately
A little bit
Not at all

14 / 18

Compared to 12 weeks ago are you now

Feeling more grief, sadness or sense of loss ?

Extremely
A lot
Moderately
A little bit
Not at all

15 / 18

Compared to 12 weeks ago are you now

Having arguments with your partner ?

Extremely
A lot
Moderately
A little bit
Not at all

16 / 18

Compared to 12 weeks ago are you now

Fearing more about losing your job ?

Extremely
A lot
Moderately
A little bit
Not at all

17 / 18

Compared to 12 weeks ago are you now

Feeling more worried about your children’s future ?

Extremely
A lot
Moderately
A little bit
Not at all

18 / 18

Compared to 12 weeks ago are you now

Over worked, exhausted or burnt out ?

Extremely
A lot
Moderately
A little bit
Not at all

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