Depression & Anxiety Review

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Key Points

- This secure form will allow you to provide the information your GP team needs to review your mental health (depression and/or anxiety).
- Your answers may not be seen immediately meaning this service is not suitable for seeking urgent or emergency care.
- If you feel you are a current risk to yourself or others please stop now and contact the practice or urgent care services (111).
- This form should only be used by someone over the age of 13.
- When you are ready to complete your review, click the "Review my Mental Health" tab above.


Your Details:
DOB:
These questions relate to your general health.
How many Standard Drinks of alcohol do you have on average each week?
How much / what do you smoke each day (if anything)?
How would you like to enter your height and weight?
Your BMI is one indicator of a healthy weight.

Your BMI: Please provide your height and weight

These questions relate to your mood

Over the last 2 weeks, how often have you been bothered by any of the following?

Moving or speaking so slowly that other people could have noticed OR Being so fidgety or restless that you have been moving around a lot more than usual
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
Thoughts that you would be better off dead, or of hurting yourself in some way
Trouble falling or staying asleep, or sleeping too much
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling tired or having little energy
Poor appetite or overeating
Any more detail about your mood (non-urgent)?
These questions relate to your Anxiety

Over the last 2 weeks, how often have you been bothered by the following?

Feeling nervous, anxious or on edge?
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?
Any more detail about your anxiety (non-urgent)?
These questions relate to your medications.
Do you take any regular medicines for your mood or anxiety?
Are you happy for a clinician to see your responses and complete your review without further discussion (if appropriate)?

Questions, concerns or additional comments: