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.
Can we contact you by email? *
Can we contact you by text message? *

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: *

Please note that the details you give will be used to update your medical records.

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