Anti-depressant Medication Review

Patient Warning

Do not use this form in an emergency. If you require immediate help or are considering self harm, you can seek help and advice today by calling the practice, NHS 111, or the crisis team on 0300 5555 001.

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

You can get further information via our Wellbeing Centre:

Anti-depressant Medication Review

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 visit NHS: Stopping or coming off antidepressants for more information about your choice.

Please choose from the following options: *

For immediate help

Do not use this form in an emergency. If you require immediate help or are considering self harm, you can seek help and advice today by calling the practice, NHS 111, or the crisis team on 0300 5555 001.

Do you have 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 require immediate help or are considering self harm, you can seek help and advice today by calling the practice, NHS 111, or the crisis team on 0300 5555 001.

Do you have 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? *

Wellbeing Matters Service and Crisis Team

Please read our Staffordshire and Stoke-on-Trent Wellbeing Service Leaflet.

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