Anti-depressant Medication Review

Patient Warning

Do not use this form in an emergency. If you are having a mental health crisis or are considering self-harm, please seek help immediately by visiting Urgent Help for Mental Health.

If you have been advised by the surgery to submit a medication review, please submit this form.

Anti-depressant Medication Review

Smoking

Smoking status: *
Would you like help to quit smoking? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Review

Please use date format: DD/MM/YYYY
How long do you think you will be taking it? *
Please choose from the following options: *

For immediate help

Do not use this form in an emergency. If you are having a mental health crisis or are considering self-harm, please seek help immediately by visiting Urgent Help for Mental Health.

Were you prescribed this medication for depression or low mood? *

PHQ-9

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: *

For immediate help

Do not use this form in an emergency. If you are having a mental health crisis or are considering self-harm, please seek help immediately by visiting Urgent Help for Mental Health.

Were you prescribed this medication for anxiety? *

GAD-7

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

Feeling nervous, anxious, or on edge *
Not being able to stop or 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 *
If you checked off any problems, 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? *
*