Mental Health Review

Please fill in this form and bring it with you to your health check.

Mental Health Questionnaire

By giving us your phone number you are consenting to the practice sending SMS messages to you.

If you do not wish to receive SMS messages from the practice, please let us know.

Do you have a carer?

Carer Information

Review Questions

Do you have a community mental health team key worker? *
If you are between 60 and 74 years old have you received a home testing kit for bowel cancer?
If you are diabetic, have you received your annual diabetic eye test?
If you are female and between 25 and 49 years old have you had a cervical screening in the last 3 years?
If you are female and between 50 and 64 years old have you had a cervical screening in the last 5 years?
If you are female and between 50 and 70 years old have you had a breast cancer screening in the last 3 years?
If you are male and aged 65 did you receive an invite for Abdominal Aorta Aneurysm screening?

Do you have a family history of any of the following:

Cardiovascular Disease *
Respiratory Disease *
Diabetes *
Cancer *
Do you have any problems with your medication? *
Do you take any drugs that have not been prescribed? *
e.g. Cannabis
Do you drink alcohol? *
Are you aware of the recommended maximum units of alcohol per week? *
Do you smoke? *