Mental Health Review

If you have been advised by the surgery to submit a mental health review please use this form.

Mental Health Review

Mental Health Review

About You

Please use this date format: DD/MM/YYYY.

We will only use this email address for correspondence in relation to this request and will not sell it onto third parties.

Mental Health Review

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *
Social situations due to a fear of being embarrassed or making a fool of myself *
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) *
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying) *

Alcohol Consumtion

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Alcohol Consumption - Part 2

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.
How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Blood Pressure Reading

Please note that if you do not have a home blood pressure monitor this can be done in the practice using our Surgery Pod. There is no need to make an appointment for this to be done.
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