Mental Health Survey Template

Patient survey template based on overall mental health.



   
 
 


Please take a few minutes to fill out this survey on the overall status of your mental health. We value your feedback and your responses will be kept confidential. Thank you for your input.


Please provide us with the following information.

 
   
 
1. What is your gender?
 
Male
 
Female
 
   
 
4. What is the highest level of education you have attained?
 
Primary school
 
Some high school
 
High school diploma or GED
 
Some college
 
2 year college degree
 
4 year college degree
 
Graduate level degree
 
Other
 
   
 
5. What is your marital status?
 
Married
 
Widowed
 
Divorced
 
Separated
 
Single never married
 
   
 
6. Are you disabled?
 
Yes
 
No
 
   
 
7. Please mark your annual gross income?
 
0 to $10,000
 
$10,001 to $25,000
 
$25,001 to $50,000
 
$50,001 to $100,000
 
$100,001 to $250,000
 
$250,001 +
 
I prefer not to answer
 
   
 
8. Which of the following group of race best describes you?
 
White
 
Black or African American
 
American Indian
 
Asian
 
Hispanic or Latino
 
Two or more races
 
   
 
9. Overall how would you rate your mental health?
 
Excellent
 
Somewhat good
 
Average
 
Somewhat poor
 
Poor
 
Not sure
 
   
 
10. Is there a history of mental disorder in your family?
 
Yes
 
No
 
   
 
11. Have you ever been diagnosed with a mental disorder before?
 
Yes
 
No
 
   
 
12. Have you ever been committed?
 
Yes
 
No
 
   
 
13. Are you currently taking any medication?
 
Yes
 
No
 

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