wellness survey

Emotional Wellness Check (Educational Sample)

(Disclaimer: This is NOT a diagnostic tool. Consult a healthcare professional for diagnosis.)

Over the last two weeks, how often have you been bothered by the following problems? (Check all that apply):

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself—or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

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

Thoughts that you would be better off dead, or of hurting yourself in some way

Your Sample Score: (Total items checked)

Sample Response:

⚠️ **If you checked question 9, please seek help immediately.** This is an educational tool, not a diagnostic one.