Mental Illness Questionnaire


A mental illness questionnaire is used to obtain information and understand mental illness issues and attitudes. The need for developing a mental illness questionnaire may differ based on the need and can be used to evaluate an individual’s mental condition, get opinions on mental illness knowledge and programs etc.

The response received from this type questionnaire also gives room to understand the opinions individuals have on mental illness.  If successfully used, a mental illness questionnaire should be able to provide an opportunity for physical and mental wellness of an individual. The questions must be easy to understand and direct.  Below is a sample.

Sample Mental Illness Questionnaire

Please fill in the information below

The first letter of your first and last name:

Date of birth: _________________________

What year are you presently in? ___________________________

Please specify your gender:

Male:  __________________

Female: __________________

Have any other members of your family ever suffered from any type of mental illness?  (Please tick where applicable)

Yes   __________________

No   __________________

Do you know of any mental illness conditions? Please list below

__________________

__________________

__________________

What do you understand by the term mental illness?

________________________________________________________________________

Do you know of any signs that may indicate that a person is suffering from mental illness?

________________________________________________________________________

________________________________________________________________________

Which signs do you think mental illness patients show?

________________________________________________________________________

________________________________________________________________________

What do you understand by the term phobia?

________________________________________________________________________

________________________________________________________________________

What do you understand by the term clinical depression?

________________________________________________________________________

________________________________________________________________________

Would you recommend treatment for an individual suffering from mental illness?

________________________________________________________________________

________________________________________________________________________

Do you agree/disagree that people with mental illness tend to be violent or dangerous?

_____

What does becoming a patient in a mental hospital mean to you?

________________________________________________________________________

________________________________________________________________________

Thank you for completing this questionnaire.

For official use only

________________________________________________________________________

________________________________________________________________________

Category: Medical Questionnaire

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