1.Overall how would you rate your mental health?

Excellent

Very good

Good

Fair

Poor

2.During the past two weeks how often have you felt sad or depressed?

Extremely often

Very often

Somewhat often

Not so often

Not at all often

3.During the past two weeks how often has your mental health interfered with your personal relationships?

Extremely often

Very often

Somewhat often

Not so often

Not at all often

4.During the past two weeks how often has your mental health interfered with your ability to get work done or accomplish tasks?

Extremely often

Very often

Somewhat often

Not so often

Not at all often