General Health Questionnaire
Please answer this questionnaire based on how you have been feeling over the last few months, on or off your medication.
Patient Name
*
D.O.B:
*
/
Day
/
Month
Year
Email
*
example@example.com
1. General Physical health
Weight change:
*
Often
Sometimes
Rarely/ Never
Sleep Problems:
*
Often
Sometimes
Rarely/Never
Low Energy:
*
Often
Sometimes
Rarely/ Never
Pain:
*
Often
Sometimes
Rarely/ Never
Feeling anxious, stressed or on edge / "panicky"?
*
Often
Sometimes
Rarely/Never
Feeling less enjoyment in life/depressed?
*
Often
Sometimes
Rarely/ Never
Repetitive thoughts or actions which are hard to control?
*
Often
Sometimes
Rarely/ Never
Feeling persistently over-excited/over-energised?
*
Often
Sometimes
Rarely/ Never
Feeling people are against you?
*
Often
Sometimes
Rarely/Never
Losing touch with reality?
*
Often
Sometimes
Rarely/ Never
Excessive alcohol consumption?
*
Often
Sometimes
Rarely/ Never
Using illicit drugs? (e.g. marijuana, cocaine, methamphetamine, MDMA)
*
Often
Sometimes
Rarely/ Never
What are your current prescribed medications? (Name, dosage, amount per day)
*
Submit
Should be Empty: