Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in the Province of Zamboanga del Norte
KATIPUNAN CAMPUS
Katipunan, Zamboanga del Norte

COLLEGE OF EDUCATION
Demographic Data of the Research Respondents

Name:____________________________Age:______________________

Gender:___________________________Civil Status:________________

Course/Program: ____________________Year of Study:_____________

Family Monthly Income:( Please check on the space provided)

8,000-10,000 [ ]

6,000-7,999 [ ]

4,000-5,999 [ ]

2,000-3,999 [ ]

1,000- below [ ]

Living Condition: (Put a check on the space provided that corresponds to your answer)

Live Alone [ ]

Live with parents [ ]

Live with one of parents [ ]

Live with my own family [ ]

Live with friends/roommates [ ]

 Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in the Province of Zamboanga del Norte
KATIPUNAN CAMPUS
Katipunan, Zamboanga del Norte

COLLEGE OF EDUCATION
Name (Optional):_____________________ Age:___________________
Program/Year Level:__________________ Gender:_________________

Direction: Please check (/) and rate yourself honestly. Your honesty in answering this questionnaire will
help us a lot in determining the Mental Health issues during pandemic.
20. I have felt calm and relax.
Yes, Yes, No No not at
21. .I have felt active and vigorous. definitely sometimes not much all
22. My daily life has been filled with (4) (3) (2) (1)
things
1. I feelthat interest
anxious me. I go out on the
when
house on my own.
23. .I woke up feeling fresh and
2. I get palpitations, or sensations of
rested .
“butterflies” in my stomach or chest.
3. I feel scared or frightened.
24. I feel hopeful about the future.
4. I am more irritable than usual.

5. I get very frightened or have panic

feelings for apparently no reason at all.
6. I am restless and can’t keep still.

7. Worrying thoughts constantly go

through my mind.
8. I wake up early and then sleep badly
for the rest of the night.
9. I feel miserable and sad.
10. I have a good appetite.
11. I feel life is not worth living.
12. I still enjoy the things I used to do.
13. I feel as if I have slowed down
14. I have lost interest in things.

15. I experienced mood swing.

16. Feel fear.

17. Experience tiredness
18. Often feel confused.
19. I am sad.

20. I have felt cheerful and in good

spirit.