QUESTIONNAIRE

DEGMNHS STUDENTS HAVING TONS OF COURSEWORK WHILE BATTLING MISERABLE

MENTAL ILLNESS

NAME:_________________________________ GRADE:________
STRAND OR SECTION: ____________ GENDER:_____ AGE:______

I. MENTAL DISORDER IMPACT

DIRECTIONS: Encircle the letter of your chosen answer.

1. Does depression or anxiety affect the way you do your schoolwork’s?

A. Highly affected
B. Affected
C. Possibly affected
D. Littler affected
E. Not affected

2. In a scale of 1 to 5, how bad does your mental illness influence you as a learner.
A. 1 (not bad)
B. 2 (solely bad)
C. 3 (slightly bad)
D. 4 (bad)
E. 5 (extremely bad)

3. Do you think like you’re a burden to your family or to your own self?
A. All the time
B. Regularly
C. Slightly
D. Rarely
E. Never

II. SCALING MENTALITY

DIRECTIONS: Check the three table below concerning your mental illness, put a check in the column
which truly fits your choice. There are 1-5 scales in the following:
HIGHLY AFFECTED - 5
AFFECTED - 4
POSSIBLY AFFECTED - 3
FAINTLY AFFECTED - 2
NOT AFFECTED - 1

I. ACADEMIC PERFORMANCE 1 2 3 4 5
1. I feel down, depressed, or hopeless in the middle of doing school works.
2. I am failing a lot of subjects recently.
3. I have little or no interest in participating to school activities.

II. MENTAL HEALTH 1 2 3 4 5

1. I sense anxiety, nervousness, or on edge in class.
2. I feel bad about myself, or that I am a failure, or scared of letting me or
family down?
3. I’m not able to stop or control worrying.
4. I am so restless, that i self-harm or thinks suicidal thoughts.

III. SOCIAL SKILLS PROBLEM 1 2 3 4 5

1. I develop no social self-regulation.
2. I have no self confidence in talking to teachers.
3. I’m not gaining any relationship skills.