Mental Health Review

Many of our usual procedures have been amended in response to the current Coronavirus pandemic. Please check our Coronavirus Updates page for the most up to date guidance.

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

Please do not use this service for any urgent medical queries as this service is only monitored during practice working hours on a daily basis.

Please note: If you have an urgent medical query you should telephone the surgery or contact the out of hours service by calling 111.

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) *
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