A mental-health self-awareness worksheet can organize observations and support questions. It should not score your worth, label a disorder, or imply that completing a form substitutes for professional assessment.
Work through these questions: Repeated worry
Completed fictional example — SAMPLE DATA
This example shows how to fill in the form. It is not a real person’s record, a diagnosis, a validated assessment or a promised outcome. Use your own observations and appropriate professional advice for actual health concerns.
| Question or field | Your entry |
|---|---|
| Observed concern? | Had difficulty concentrating during one meeting |
| Duration context? | Noted during this fictional afternoon only |
| Daily impact? | Needed to reread the agenda |
| Support already used? | Asked a colleague to clarify the task |
| Care question? | What assessment is appropriate if this persists or worsens? |
Blank worksheet — copy or print
Copy the form into your own private document or print this page. Replace each “Your entry” cell with your own note; leave anything uncertain clearly marked as unknown. This page does not save or submit your entries.
| Question or field | Your entry |
|---|---|
| Observed concern? | Your entry |
| Duration context? | Your entry |
| Daily impact? | Your entry |
| Support already used? | Your entry |
| Care question? | Your entry |
Completed example
| Question or field | Fictional completed example |
|---|---|
| Observed concern? | Repeated worry |
| Duration context? | Dates when it occurred |
| Daily impact? | Missed an ordinary activity |
| Support already used? | Conversation with a trusted person |
| Care question? | What assessment would be appropriate? |
A worked situation: Repeated worry
Fictional example. A reader records worry, sleep disruption, and missed ordinary activities. She uses the record to explain the pattern to a clinician without deciding the diagnosis from the number of boxes marked.
Use the form for a care conversation
Describe the concern, how long it has been noticeable, and the ordinary activities it affects. Separate your own words from another person’s observation. The worksheet has no cutoff score and does not determine whether a diagnosis applies. If recording itself becomes a source of repeated checking, pause it and discuss a more appropriate way to communicate the concern.