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.

Please fill in the following form for your mental health review.

Do you consent for us to contact you via text message or email:
Would you like to receive test results via text message?
Date of Birth Required
Are you currently on antidepressant medication? Required
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.

Little interest or pleasure in doing things Required
Feeling down, depressed, or hopeless Required
Trouble falling/staying asleep, sleeping too much Required
Feeling tired or having little energy Required
Poor appetite or overeating Required
Feeling bad about yourself or that you are a failure or have let yourself or your family down Required
Trouble concentrating on things, such as reading the newspaper or watching television Required
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. Required
Thoughts that you would be better off dead or of hurting yourself in some way. Required
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? Required

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