This form is only to be completed if you have been asked to as part of a Mental Health Review by the practice.
If yes please select one of the follow statements
Please answer the questions below based on over the last 2 weeks and how often you have been bothered by any of these problems.
The following questions are marked on a scale of 0-8 depending on how much you avoid the circumstances described.
0 = Would not avoid it, 2 = Slightly avoid it, 4 = Definitely avoid it, 6 = Markedly avoid it, 8 = Always avoid it.
In-between answers (1, 3, 5, 7 are allowed)
Your medical records will be updated with the information provided in this form
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to Parkside Medical Centre, Boston • Tawney Street, Boston, Lincolnshire, PE21 6PF.
Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.
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