Wellbeing Checks Background Questions Wellbeing Checks - Background Questions First Name*Last Name* Past Mental Health History Do you have a past mental health issue? Yes No Diagnosis:Year of diagnosis:Psychological treatment: Yes No Medication: Yes No If yes, please list:Outcome: Current Diagnosis Nil disclosed If known, please specify: Current Reported Symptoms Cognitive Symptoms (tick any that apply) Poor concentration Memory difficulties Indecisiveness Racing thoughts Intrusive or unwanted thoughts Mental fatigue Other If you ticked other, please specifySomatic (Physical) Symptoms Sleep disturbances (difficulty falling or staying asleep) Fatigue or low energy Muscle tension or aches Headaches Gastrointestinal issues (e.g., nausea, upset stomach) Changes in appetite or weight Other If you ticked other, please specifyEmotional Symptoms Persistent sadness or low mood Anxiety or excessive worry Irritability or anger Feeling overwhelmed Numbness or emotional detachment Low motivation or interest in usual activities Feelings of hopelessness or helplessness Other If you ticked other, please specify Triggers Triggers High workload Conflict or interpersonal issues Financial stress Major life changes (e.g., loss, separation, relocation) Other If you ticked other, please specify Risk Assessment Suicidality/Self Harm Have you had past suicidal attempts? Yes No If yes, please describe:Do you have current suicidal ideation, intent or plans? Yes No If yes, please describe:Risk Level (if known): Low Moderate High Work-related Burnout Do you have: No concerns Some concerns High risk (e.g. emotional exhaustion, reduced performance) If you have some concerns, please describe what they are: Exposure to Trauma I have had no exposure to trauma I have exposure to a traumatic work-related event If you ticked yes to the question above, have you: Debriefed with supervisor/colleagues Received psychological support If you have had exposure to a traumatic work-related event, please describe the event (if comfortable):I have had exposure to personal life trauma Exposure to personal/life trauma (please describe if comfortable): Other Medical History Other Medical History Nil known medical conditions Existing medical condition(s) If you have an existing medical condition, please specify:Do you take medication? Yes No If yes, please list: EmailThis field is for validation purposes and should be left unchanged.
