Mental Health Review Form Mental Health Questionnaire If you are human, leave this field blank. If you have been advised by the surgery to submit a mental health review, please use this form. Name * Date of Birth (dd/mm/yyyy) * Address: * Email Address (only fill this in if you are happy or us to use this to contact you) Are you happy for us to contact you via text message and email? * Yes No Are you happy to receive test results by text messaging? * Yes No If you are already on antidepressant medication, please check the relevant box: * I am happy with my current dose of anti-depressant, have no side effects and would like to continue on this medication currently. I am happy for the doctor to update my medication review now. I have taken my anti-depressants now for more than 6 months, am feeling well and would like to think about reducing my dose. I do not think my depression is controlled by my current anti-depressant and would like a doctor/nurse/clinical pharmacist to contact me about this. I am not currently taking any antidepressant medication. Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things: * Not at all Several days More than half the days Nearly every day Feeling down, depressed, or hopeless: * Not at all Several days More than half the days Nearly every day Trouble falling or staying asleep, or sleeping too much: * Not at all Several days More than half the days Nearly every day Feeling tired or having little energy: * Not at all Several days More than half the days Nearly every day Poor appetite or overeating: * Not at all Several days More than half the days Nearly every day Feeling bad about yourself — or that you are a failure or have let yourself or your family down: * Not at all Several days More than half the days Nearly every day Trouble concentrating on things, such as reading the newspaper or watching television: * Not at all Several days More than half the days Nearly every day 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: * Not at all Several days More than half the days Nearly every day Everyday thoughts that you would be better off dead or of hurting yourself in some way * Not at all Several days More than half the days Nearly every day 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? * Not difficult at all Somewhat difficult Very difficult Extremely difficult Declaration * I confirm that the information provided is accurate to the best of my knowledge Please leave this blank Submit
