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Psychological Problems Identification Survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Do you often feel anxious or worried?
Please select the option that best describes your current state.
Yes
No
2
On a scale of 1 to 10, how would you rate your overall happiness?
Rate your overall happiness on a scale from 1 to 10, where 1 is extremely unhappy and 10 is extremely happy.
3
Describe your current state of mind in a few words.
Please provide a brief text answer describing your current state of mind.
4
Do you experience mood swings frequently?
Please select the option that best describes your mood swings.
Frequently
Sometimes
Rarely
5
How often do you feel overwhelmed by daily tasks?
Please select the option that closely represents your experience.
Always
Often
Sometimes
Rarely
Never
6
Are you able to concentrate on tasks for a long period of time?
Select the option that best describes your ability to concentrate on tasks.
Yes
No
7
How often do you experience feelings of loneliness?
Select the option that closely matches your experience of loneliness.
Always
Often
Sometimes
Rarely
Never
8
In a typical week, how many days do you feel low on energy?
Please select the approximate number of days in a week when you feel low on energy.
0 days
1-2 days
3-4 days
5-6 days
Every day
9
How important is social interaction for your overall well-being?
Rate the importance of social interaction in your life.
10
Do you have trouble falling asleep at night?
Select the option that best describes your sleeping patterns.
Yes
No
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