Kessler 5 (K5) form

Please complete all information required in the form fields below

Kessler 5 (K5)

Name *

Date of Birth *

Address
Address Line 1
City
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This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

The following five questions ask about how you have been feeling in the past four weeks. For each question select the box nest to the option that best describes the amount of time you have felt that way.

Date / Time

Name