Mental Health Review

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We are using this secure online system to help assess your mental health and gather some relevant lifestyle information. Your answers will always be seen by the practice team, and you can indicate at the end if you feel further discussion is needed.

YOU WILL NEED: Recent weight and height

OPTIONAL: You can enter a single recent blood pressure reading and pulse rate.

SAFETY: If you feel you are a risk to yourself or others please stop now and contact the practice.

Your answers will be attached to your medical record but may not be seen immediately. This system should never be used if you are in need of urgent medical attention. In this event, please contact the appropriate services (999 or 111) or the practice as normal.

If text is too small on your device, turn it sideways. You can also type the link you received into a tablet or computer browser to view on a larger screen

Practice Name - OFFICE USE ONLY *

This review is only for patients registered at the practice below. Please do not change under any circumstances

Data Processing Notice

Participation

To participate in this online review you must confirm the following by ticking each box. If you are unable to do so please contact the practice

I am 18 years of age or older

I am currently located in the United Kingdom

I am a registered patient at the above named practice

I elect to participate in this online review in accordance with the Data Processing Notice above, which I have read and understood

First name *

Surname *

Month of birth *

Day of birth *

Year of birth *

Ethnicity *

This information is helpful because some ethnic groups are at higher risk of certain medical problems. Options are taken from the most recent UK census. If your ethnicity is not specified, you can enter it in 'Other', and if you would rather not say please select that option at the bottom of the list

White - British

White - Irish

White - any other white background

Mixed - white and black Caribbean

Mixed - white and Asian

Mixed - white and black African

Mixed - any other mixed background

Asian - Indian

Asian - Pakistani

Asian - Bangaldeshi

Asian - any other

Black - Caribbean

Black - African

Black - any other black background

Chinese

I would rather not say

Other:

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