Full Name
*
Email
*
Phone
How often have you felt emotionally overwhelmed or "not yourself" lately?
*
Never
Occasionally
More than half the days
Nearly every day
How often do you feel anxious or on edge, even when there’s no clear reason?
*
Never
Sometimes
Often
Constantly
Are you finding it hard to enjoy things you used to enjoy?
*
No
A little
Quite a bit
Yes, completely
Have you had trouble falling asleep, staying asleep, or waking too early?
*
No issues
Occasionally
Most nights
Every night
How often do you feel tired or drained, even after a full night’s sleep?
*
Rarely
Sometimes
Most days
Every day
Are you experiencing difficulty concentrating or staying focused?
*
Not at all
Occasionally
Often
Very often
Do you experience racing thoughts or an inability to calm your mind?
*
No
Sometimes
Regularly
Constantly
How often do you feel irritable, agitated, or unusually impatient?
*
Rarely
Occasionally
Often
Very often
Have you been withdrawing from social situations or avoiding people?
*
No
A little
Frequently
Almost always
Do you feel overwhelmed by everyday tasks or decisions?
*
Never
Occasionally
Most days
Daily
Have you experienced any changes in appetite (eating much more or much less)?
*
No changes
Slight changes
Noticeable change
Extreme change
Are you having thoughts like “What’s the point?” or feeling hopeless?
*
Never
Occasionally
Frequently
Constantly
Do you feel physically tense, like your body won’t relax?
*
Not at all
Occasionally
Often
Always
Are you feeling emotionally numb or disconnected from your surroundings?
*
Not at all
Sometimes
Often
Constantly
Would it feel helpful just to talk to a doctor and understand what’s going on?
*
No
Maybe
Probably
Yes
