First Name
Last Name
Mental Health can affect one's ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity.
*
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
Because of my mental health, my ability to work is impaired.
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
Because of my mental health, my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired.
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
Because of my mental health, my social leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertaining) are impaired.
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
Because of my mental health, my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired.
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
Because of my mental health, my ability to form and maintain close relationships with others, including those I live with, is impaired.
0 (Not at all)
1
2 (Slightly)
3
4 (Definitely)
5
6 (Markedly)
7
8 (Very Severely)
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Total
Low Impairment
Moderate Impairment
Severe Impairment
