Chronic Illness Mental Health Assessment Form
Personal Information
Full Name
Date of Birth
Primary Chronic Illness
Duration of Illness (years)
Mental Health Assessment
In the past month, how often have you felt anxious or stressed?
Never
Sometimes
Often
Always
How would you rate your mood most days?
Good
Neutral
Low
Do you have difficulty sleeping?
Yes
No
Have you experienced any of the following? (Select all that apply)
Fatigue
Loss of interest
Appetite changes
Irritability
Other symptoms or concerns
Coping & Support
How would you describe your current support system?
Strong
Average
Weak
None
What coping strategies do you use?
Additional Comments