Mental Health Review

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

Required field(s) are indicated by *
Mental Health Review
Which surgery are you registered with? *
About you

First Name(s) as appears on your passport.

Last Name(s) as appears on your passport.

The one used to register with your GP.

Your date of birth is required to verify your identity.

As on your medical record.

The practice may use this number to contact you about your request.

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

Your Health

Are you happy to provide your height and weight? *

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use format: DD/MM/YYYY
/

Smoking

Smoking status: *

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 do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Next Steps

As part of your mental health review, please
request an appointment for a cholesterol blood test and HbA1c blood test.

You will then have a follow up phone call with your GP to complete a care plan and discuss the results of your blood tests.

*