Mental Health Assessment

This form is confidential and will only be viewed by My Occ Health once completed. Please ensure you complete the assessment in full as any failure to provide information will result in your assessment being delayed whilst we query the information.

Your details

Name*

First Last

Date of birth*

DD

MM

YYYY

Sex*

Male
Female

Address*

Address Line 1 Address Line 2 City County Postcode Country

Email address*

Confirm email address*

Phone number*

Job title*

Date of commencement*

Referral code (if applicable)

Anxiety

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious or on edge*

Not at all
Several days
More than half the days
Nearly every day

Not being able to stop or control your worrying*

Not at all
Several days
More than half the days
Nearly every day

Worrying too much about different things*

Not at all
Several days
More than half the days
Nearly every day

Trouble relaxing*

Not at all
Several days
More than half the days
Nearly every day

Being so restless it is hard to sit still*

Not at all
Several days
More than half the days
Nearly every day

Becoming easily annoyed or irritable*

Not at all
Several days
More than half the days
Nearly every day

Feeling afraid as if something awful might happen*

Not at all
Several days
More than half the days
Nearly every day

Depression

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things*

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed or hopeless*

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too much*

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy*

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating*

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself – or that you are a failure or have let yourself or your family down*

Not at all
Several days
More than half the days
Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual*

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things such as reading the newspaper or watching the television*

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way*

Not at all
Several days
More than half the days
Nearly every day

Workplace stress

Please answer the following questions in relation to your current role and duties at work

I am clear what is expected of me at work*

I have unachievable deadlines*

I am given specific feedback on the work I do*

I am unable to take sufficient breaks*

I am subject to bullying at work*

I have unrealistic time pressures*

I get help and support I need from colleagues*

I have some say over the way I work*

Staff are always consulted about change at work*

I can talk to my line manager about something that has upset or annoyed me at work*

Relationships at work are strained*

Payment

Your form will be sent to our team for review once you have completed payment

Mental Health Assessment*

Price:

includes VAT

Credit Card

Card Details

Cardholder Name

Voucher code

Cost (inc VAT)

£ 0.00