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The Allan Practice

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Chalfonts PCN
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Appointments
Prescriptions
Health Advice
New Patients
Chalfonts PCN
Contact Us

Language
Home
News
Information
Opening Hours
Our Staff

Mental Health Review

Last Updated: 14/08/2020

Personal Details

First name *

Surname *

Date of birth *

Physical Health

How many units of alcohol do you drink each week? *

Do you consider your diet to be healthy? *

Yes No

Do you take part in exercise / physical activity? *

Yes No

Do you use recreational or non-prescription drugs (e.g. cannabis)? If yes, what do you use? *

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes per day)

Heavy (20-39 cigarettes per day)

Very heavy (40+ cigarettes per day)

Rolls own cigarettes

Smokes a pipe

Smokes cigars

Please enter your current weight. *

Please enter your most recent blood pressure reading if known.

Mental Health

Are you currently under the care of the mental health department? *

Yes No

Do you have an allocated community psychiatric nurse, care coordinator or social worker? *

Do you currently work? This can include paid or volunteer positions you hold. *

Do you have any problems with your medication/s? *

Questions or concerns

Do you have any questions or concerns?

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