Welcome
Mental Health Support Helpline
The Set of Questions answered by Healthcare worker
Please call helpline number
72920 18816
if you have difficulty filling this form
Please complete following information
--- Select One ---
Yes
No
Are you a healthcare worker?
--- Select One ---
Doctors
Nurse
Allied Health Professional
Clinical Administration
Healthcare Support Staff
Healthcare Volunteer
Others
Role
Other (Please Specify)
--- Select One ---
Emergency/Intensive Care
Regular Inpatient Care
Outpatient Care
Remote Health
Healthcare Category - Majority Work
--- Select One ---
Direct Exposure to Covid patients
Intermittent/Indirect Exposure to Covid Patients
No Direct Exposure to Covid Patients
Remote Health
Covid Exposure at work
Name of The Healthcare Facility
Mobile Number
Email Id
First Name
Last Name
Age
State
City
Gender
Gender
Male
Female
Other
Gender
Language
English
Hindi
Tamil
How are you feeling today?
---Select One---
Stressed
Normal
Tensed
Were you tested positive for Covid-19 in the past?
Yes
No
Were someone in your Close Family tested positive for Covid-19 in the past
Yes
No
Are you vaccinated?
Yes
No
Select Vaccination Type
Covaxin
Covishield
Others
Vaccination Type
Other Vaccination
Dose 1
Dose 1 And Dose 2
Date of Vaccination Dose 1
Date of Vaccination Dose 2
On an Average, how many hours do you work in a day?
--- Select One ---
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
13 hours
14 hours
15 hours
16 hours
17 hours
18 hours
19 hours
20 hours
21 hours
22 hours
23 hours
24 hours
How frequently do you take off from work?
--- Select One ---
More than Once in a week
Once in a week
Once in 2 weeks
Less than Once in 2 weeks
How often do you feel anxious/tensed?
Before Pandemic:
Never
Rarely
Sometimes
Often
Very Often
During Pandemic:
Never
Rarely
Sometimes
Often
Very Often
How often do you feel stressed/overwhelmed?
Before Pandemic:
Never
Rarely
Sometimes
Often
Very Often
During Pandemic:
Never
Rarely
Sometimes
Often
Very Often
How often do you feel low/helpless/depressed?
Before Pandemic:
Never
Rarely
Sometimes
Often
Very Often
During Pandemic:
Never
Rarely
Sometimes
Often
Very Often
How often do you have difficulty falling asleep?
Before Pandemic:
Never
Rarely
Sometimes
Often
Very Often
During Pandemic:
Never
Rarely
Sometimes
Often
Very Often
During the pandemic
Select all the options that have become applicable to you during the pandemic
Loss of Appetite
Loss of Self Esteem
Increased consumption of Alcohol
Increased usage of sedatives
Increased Fear/Death Anxiety
Trouble Concentrating
Constant Feeling of Tiredness
Suicidal Thoughts/Thoughts of Self Hurt
Others
Others
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