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.

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) *

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

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