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Mental Health Review (ICD-10) Form

Mental Health Review (ICD-10)
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Please use format day/month/year e.g. 12/05/1979

Your Mental Health Review

The following questions ask about how you have been feeling over the last two weeks. Please select the option which is closest to how you have been feeling.

Have you felt in low spirits or sad? *
Have you lost interest in your daily activities? *
Have you felt lacking in energy and strength? *
Have you felt less self-confident? *
Have you had a bad conscience or feelings of guilt? *
Have you felt that life wasn’t worth living? *
Have you had difficulty in concentrating, e.g. when reading the newspaper or watching television? *
Have you felt very restless? *
Have you felt subdued? *
Have you had trouble sleeping at night? *
Have you suffered from reduced appetite? *
Have you suffered from increased appetite? *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.