Depression/Anxiety Review

 
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

Thank you for completing this annual review form. This is to ensure we are monitoring patients' conditions adequately, which helps us to provide better care to our patients who suffer with mental health conditions.

This form is for patients with Depression, Anxiety, or both, who feel their condition is well controlled. Please do not complete this form if you prefer to consult a GP or have concerns or issues regarding your mental health that you would like to discuss (this includes worsening mood or anxiety level, issues with self-harm and/or suicidal thoughts. If you are experiencing these issues please contact the surgery urgently or alternatively call 111 or attend Accident and Emergency. The Sussex Mental Health Line can be used for further support on 03005000101).

Do not complete this form if this is a new presentation/problem as this will require a GP consultation.

The form will be downloaded and added onto your health records upon submission to our medicines management team who will notify your GP and update your record.

You will only be contacted by a member of our clinical team if there are any queries regarding your medication or condition.

Personal Details
Processing
Condition
Diagnosis/Condition:
Select all that apply
Counselling/CBT
Have you had any counselling/CBT?: *

Cognitive behavioural therapy (CBT) has been shown to be an effective way of treating a number of different mental health conditions including depression and/or anxiety. This can be accessed through self referral locally. 

Access talking therapies

Medication
Do you take medication for this condition?: *
Do you ever forget to take your medication?: *
Please specify how often this happens:
Would you like any changes made to your medication?: *
Please tell us what you would like to change: *

Please continue with your current dose for now.  A clinician will contact you shortly to discuss these changes.

Processing
Patient Health Questionnaire (PHQ-9)

PHQ-9 Assessment

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

(1) Little interest or pleasure in doing things?: *
(2) Feeling down, depressed, or hopeless?: *
(3) Trouble falling or staying asleep, or sleeping too much?: *
(4) Feeling tired or having little energy?: *
(5) Poor appetite or overeating?: *
(6) Feeling bad about yourself — or that you are a failure or have let yourself or your family down?: *
(7) Trouble concentrating on things, such as reading the newspaper or watching television?: *
(8) Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?: *
(9) Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?: *
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? : *
PHQ-9 Result 1 - 4 (Minimal Depression)

MINIMAL DEPRESSION - you have a score of

Scores < 4 suggest minimal depression which may not require treatment.

PHQ-9 Result 5 - 9 (Mild Depression)

MILD DEPRESSION - you have a score of

Scores 5 - 9 suggest mild depression.

PHQ-9 Result 10 -14 (Moderate Depression)

MODERATE DEPRESSION - you have a score of

Scores 10 - 14 suggest moderate depression severity.

PHQ-9 Result 15 - 19 (Moderately Severe Depression)

MODERATELY SEVERE DEPRESSION - you have a score of

Scores 15 - 19 suggest moderately severe depression.

PHQ-9 Results 20 - 27 (Severe Depression)

SEVERE DEPRESSION - you have a score of

Scores 20 and greater suggest severe depression.

Processing
Generalised Anxiety Disorder 7 (GAD-7)

GAD-7 Assessment

Over the last two weeks how often have you been bothered by the following problems?

(1) Feeling nervous, anxious, or on edge: *
(2) Not being able to stop or control worrying: *
(3) Worrying too much about different things: *
(4) Trouble relaxing: *
(5) Being so restless that it is hard to sit still: *
(6) Becoming easily annoyed or irritable: *
(7) 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? : *
GAD-7 Result 0 - 4 (No Anxiety Disorder)

NO ANXIETY DISORDER -  you have a score of 

Scores < 4 suggest No Anxiety Disorder.

GAD-7 Result 5 - 9 (Mild Anxiety)

MILD ANXIETY -  you have a score of 

Scores 5 - 9 suggest Mild Anxiety.

GAD-7 Result 10 - 14 (Moderate Anxiety)

MODERATE ANXIETY -  you have a score of 

Scores 10 - 14 suggest Moderate Anxiety.

GAD-7 Result 15 - 21 (Severe Anxiety)

SEVERE ANXIETY -  you have a score of 

Scores 15 - 21 suggest Severe Anxiety.

Processing
Further Questions

Fill out the following only if applicable.

Are you currently pregnant?:
Are you currently breastfeeding?:
Have you given birth within the last 3 months?:
Have you been known to the peri-natal mental health team?:
Do you drink alcohol?:
Do you use recreational drugs?:

Thank you for completing this annual review form. Please press submit once you are happy the above information is accurate. Your mental health should be reviewed on an annual basis but please contact the surgery if you have any new concerns or queries.

Privacy Consent

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Safe Surgeries logo Safe
Surgeries
Veteran Friendly Armed Forces veteran
friendly accredited
GP practice
lgbtq logo

Pride in
Practice

Gold

Disability Confident disability
confident Committed
Proud to be an Active Practice

Providing NHS Services

Contact

St Lawrence Surgery
79 St Lawrence Avenue
Worthing
West Sussex
BN14 7JL

Telephone: 01903 222 900

The Practice

Quick Links

The Care Quality Commission Inspected and rated Outstanding

© Tree View Designs Ltd. All rights reserved.

Facebook