HEALTH
1. In general, would you say your health is excellent, very good, fair, or poor?
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MENTAL HEALTH CONCERNS (Past 30 days)
2. To what extent have your mental health concerns interfered with your
family life?
3. To what extent have your mental health concerns interfered with your
social life?
4. To what extent have your mental health concerns interfered with your
work, schoolwork, or housework?
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EMPLOYMENT
5. Are you currently employed?
6. Have your problems caused you to have time away from your work
in the past 30 days?
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WORKDAYS
7. During the past 30 days, how many full workdays have
you missed for reasons other than vacation, holidays, or scheduled time off?
8. During the past 30 days, how many full days have you been unable to
perform your usual daily routine such as attending school, childcare,
or housework, for reasons other than vacation or holidays?
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DISABLITY
9. Are you on, have you filed for, or are you considering filing for
disability benefits or worker’s compensation?
10. Are you experiencing recent problems at work?
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WELLNESS
12. I feel good about myself.
13. I can deal with my problems.
14. I am able to maintain control over my life.
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