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Mental Health Metrics Monitoring Form Template
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Complete the form below to help us monitor changes in your mental well-being over time.
*
1.
Full name
2.
Assessment date
3.
On a scale of 1 to 10, how would you rate your current stress level?
1
10
1
2
3
4
5
6
7
8
9
10
4.
On a scale of 1 to 10, how would you rate your current mood?
1
10
1
2
3
4
5
6
7
8
9
10
5.
How many hours of sleep did you get last night?
6.
How often do you engage in physical activity each week?
Choose
Never
1-2 times
3-4 times
5 or more times
7.
Do you feel supported by friends or family?
Yes
Sometimes
No
8.
Additional comments
Evaluation object score
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