REVITALIVE: Mental Wellness Survey

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Email Address
Gender:
Gender:
Age: 
During the past few months, have you had any problems with your work or daily life due to your physical health?
During the past few months, have you had any problems with your work or daily life due to your physical health?
During the past few months, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad or anxious? 
During the past few months, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad or anxious? 
What's your happy place ( things you do to feel at peace)
Overall how would you rate your mental health?
Overall how would you rate your mental health?
Do you talk to people you trust when you feel low?
Do you talk to people you trust when you feel low?
How often do you look after your mental and physical well being?
How often do you look after your mental and physical well being?
How often do you experience the following?
Never
Once in a while
About half the time
Most of the time
Always
Calm and peaceful
Energetic
Gloomy
Angry
Does your household play a positive or negative role regarding your mental health
Does your household play a positive or negative role regarding your mental health
Does your health limit you in doing daily activities? 
Very less
Moderately
Very much
No problem
Light physical activities
Moderate physical activities
Heavy physical activities
Have you seen a therapist in the recent past or taken any medications?
Have you seen a therapist in the recent past or taken any medications?
Has your mental health gotten worse recently?
Has your mental health gotten worse recently?
How many hours do you sleep per day?
How many hours do you sleep per day?
How is your quality of sleep?
How is your quality of sleep?
What is your marital status?
What is your marital status?
Do you find yourself having any of the following:
Has the current situation/Pandemic going around the world impacted your mental health in any way?
Has the current situation/Pandemic going around the world impacted your mental health in any way?
If it has or made it worse, what circumstances have affected you?
How often do you feel positive about your life?
How often do you feel positive about your life?
Would you be open to sharing your stories or journeys anonymously to help others out?
Would you be open to sharing your stories or journeys anonymously to help others out?
Would you be interested in therapeutic activities to improve your mental wellness?
Would you be interested in therapeutic activities to improve your mental wellness?
Does your work/School play a major or minor role in your mental health?
Does your work/School play a major or minor role in your mental health?
What motivates you to keep going or moving forward?  
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