Depression Medication Review Questionnaire

If you have been advised by the practice to complete a Depression Medication Review Questionnaire please use this form.

Depression Medication Review Questionnaire

Depression Medication Review Questionnaire

About You:

Ethnic Group:
Languages Spoken:
Do you require an interpreter?

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Alcohol Intake

How much alcohol do you drink per week on average? 1 pint = 2 units

Medication

Are you taking any non-prescribed drugs or medication?

Eating Habits

Do you have any concerns about your eating habits?

Low Mood

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

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
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: *
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: *
Thoughts that you would be better off dead or of hurting yourself in some way: *

Anxiety

Feeling nervous, anxious of on edge: *
Not being able to stop of 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: *
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?: *

Are you currently:

Blood Pressure

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