Anti-Depressant Review Form

Overall Mood: On a scale of 1 - 10, how have you been feeling over all? (0= very low, 10 = very well) *

Mood: Have you been feeling low, depressed or hopeless? *

Not at all

Occasionally

Most Days

Daily

Have you had recent thoughts of harming yourself or that you would be better off dead? *

Yes

Function and Impact

How much is your mental health affecting your daily life? i.e work,home relationships? *

Not at all

Mildly

Moderately

Severely

Medication Adherence and Effect

Are you taking your medication as prescribed *

Yes

Sometimes

Do you feel the medication is helping? *

Yes

Are you experiencing any side effects from the medication? *

Mild

Significant

Please detail below any side effects.

Patient Preference

Optional final Question

Self help Resources

Please find below a list of links to useful self help resources available.

The Practice also has a Mental Health Practioner based in surgery on a Monday and Wednesday. If you wish to make an appointment please call the surgery on 01563 522118.

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Anti-Depressant Review Form

DISCLAIMER: This form will be reviewed by the GP within 2 weeks after completion and submission. If you feel that you need to discuss your medication or mental health sooner please contact the surgery to make an appointment.

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