Client Information
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Email
*
example@example.com
NHS Number
Contacts
Name of your GP
*
GP Email address
Surgery address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you give consent for us to write to your GP for reasons such as medication recommendations?
*
Please Select
Yes
No
Do you give consent for us to speak to your family for reasons such as treatment plans, welfare checks and/or other clinic-related matters?
*
Please Select
Yes
No
Are you currently under the care of a psychiatrist or mental health professional?
*
Please Select
Yes
No
Do you give consent for us to contact your psychiatrist?
*
Please Select
Yes
No
Please provide the name, address and any contact details of your psychiatrist
*
Medication name and dose
Please state all current medication
Do you have any medication allergies?
*
Yes
No
Not Sure
If yes please specify:
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PATIENT HEALTH QUESTIONNAIRE-9
PHQ 9 /27
If your responses indicate immediate concern, a clinician may contact you prior to your appointment
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
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
PHQ-9 Total
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General Anxiety Disorder
GAD-7 /21
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
*
Not at all sure
Several days
Over half the days
Nearly every day
Not being able to stop or control worrying
*
Not at all sure
Several days
Over half the days
Nearly every day
Worrying too much about different things
*
Not at all sure
Several days
Over half the days
Nearly every day
Trouble relaxing
*
Not at all sure
Several days
Over half the days
Nearly every day
Being so restless that is hard to sit still
*
Not at all sure
Several days
Over half the days
Nearly every day
Becoming easily annoyed or irritable
*
Not at all sure
Several days
Over half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Not at all sure
Several days
Over half the days
Nearly every day
GAD-7 Total
Thank you
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