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Mental Health Review

This form is only to be completed if you have been asked to as part of a Mental Health Review by the practice.

Mental Health Review

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


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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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