Mental Health Behavioral Pattern Recognition

Section 1: Basic Information

Age:
Gender:
Occupation:
Highest level of education:
Relationship status:

Section 2: General Health and Lifestyle

How would you rate your overall physical health?
Excellent Good Fair Poor
How many hours of sleep do you typically get per night?

How often do you exercise?
Daily 3-5 times a week 1-2 times a week Rarely Never
How would you describe your diet?
Very healthy Moderately healthy Somewhat unhealthy Very unhealthy
Do you smoke?
No Former smoker Yes
How often do you consume alcohol?
Never Occasionally Once a week Several times a week Daily

Section 3: Mental Health History

Have you ever been diagnosed with a mental health condition?
No Yes
Is there a history of mental health conditions in your family?
No Unsure Yes
Have you ever sought professional help for mental health concerns?
No Yes
Are you currently taking any medication for mental health?
No Yes

Section 4: Recent Behavioral Changes

Have you noticed changes in your sleep patterns?
No significant changes Sleeping much more than usual Sleeping much less than usual Difficulty falling asleep Waking up frequently during the night
Have you experienced changes in your appetite or eating habits?
No significant changes Increased appetite Decreased appetite Eating at unusual times
How would you describe your energy levels?
No significant changes Much higher than usual Much lower than usual Fluctuating significantly
Have you noticed changes in your social behavior?
No significant changes Increased desire for social interaction Increased isolation from others Difficulty maintaining relationships
Have you experienced changes in your ability to concentrate or make decisions?
No significant changes Increased difficulty concentrating Increased indecisiveness Improved focus and decision-making
Have you noticed changes in your emotional state?
No significant changes Increased irritability or anger Increased sadness or tearfulness Increased anxiety or worry Emotional numbness Extreme mood swings
Have you experienced changes in your personal hygiene or grooming habits?
No significant changes Decreased attention to hygiene Increased focus on appearance
Have you noticed changes in your work or academic performance?
No significant changes Decreased productivity Increased absenteeism Improved performance
Have you experienced changes in your interest in hobbies or activities you usually enjoy?
No significant changes Decreased interest Increased interest
Have you noticed any changes in your use of technology or social media?
No significant changes Increased use Decreased use Changes in the type of content consumed

Section 5: Stress and Coping

On a scale of 1-10, how would you rate your current stress level?

What are your primary sources of stress? (Select all that apply)
Work/School
Relationships
Financial concerns
Health issues
Family responsibilities
Other

Section 6: Additional Information

Have you experienced any significant life events in the past year?
No Yes