Unity Health

Kimberlow Hill Surgery | Wenlock Terrace Surgery

Mental Health Review Form

Mental Health Questionnaire
Are you happy for us to contact you via text message and email? *
Are you happy to receive test results by text messaging? *
If you are already on antidepressant medication, please check the relevant box: *
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: *
Everyday 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? *
Declaration *

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