SRI GANESAR HIGHER SECONDARY SCHOOL

PANICKANADANEUDIERUPPU-628212

QUESTIONNAIRE ON STUDENT WELLBEING

(CONFIDENTAL)

I. SOCIO -DEMOGRAPHIC DATA -DATE:

STUDENT NAME -

FATHER NAME -

MOTHER NAME -

ADDRESS -

STANDARD & SECTION –

MEDIUM ( TM / EM )

HOSTLER / DAYS SCHOLAR

SEX -

DOB & AGE -

CLASS TEACHER NAME -

II AT PRESENT OR IN THE LAST 1 MONTH ANY MAJOR STRESS (IN 3 SENTENCES) –DO
NOT ELABORATE

III IN GENERAL,OVER LAST 3 MONTHS (TICK YOUR CHOICE)

1. SLEEP: NO OF HOURS SLEEP IN AN AVERAGE DAY: LESS THAN 4 HOURS/4-6 HOURS /

6-8 HOURS / MORE THAN 8 HOURS

2. ANY APPETITE LOSS : YES/NO

3. DIFFICULTLY IN CONCENTRATION: YES / NO

4. MOOD STATE : LOW/ANXIOUS/ELEVATED /NORMAL

5. ANY FATIGUE /TIREDNESS/LOW ENERGY LEVEL

6. LACK OF INTREST IN STUDY : YES /NO

7. ANY FEAR/INSECURITY/LOW SELF CONFIDENCE

8. ANY UNUSUAL THOUGHTS : YES/NO

9. ANY OTHER PROBLEM : YES/NO

IV ANY PAST HISTORY OF PSYCHOLOGICAL PROBLEM : YES/NO

ANY PAST HISTORY OF MEDICAL PROBLEMS: DIABETES /

DENGUE/JAUNDICE/ANY SURGERY/ANY OTHER SPECIFY

FAMILY HISTORY OF PSYCHOLOGICAL PROBLEM IN PARENTS, GRANDPARENTS,

BROTHER/SISTER:

V RELATIONSHIP WITH PARENTS: GOOD/BAD/NORMAL

RELATIONSHIP WITH CHILDREN: GOOD/BAD/NORMAL

RELATIONSHIP WITH COLLEAGUES: GOOD/BAD/NORMAL

RELATIONSHIP WITH FRIENDS: GOOD/BAD/NORMAL

RELATIONSHIP WITH TEACHERS: GOOD/BAD/NORMAL

RELATIONSHIP WITH OTHER: GOOD/BAD/NORMAL

VI DO YOU NEED TO TAKE A BREAK/CHANGE OF SCHOOL : YES/NO

DO YOU FEEL A NEED TO TALK COUNSELLER: YES/NO

SEEN BY

(PSYCHOLOGIST)