Mental Health Review

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

Mental Health Review

Your Health

Are you happy to provide your height and weight? *

BMI

eg. 1.75
eg. 60.6
Please note: BMI calculator is only for patients aged 18 and over.

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: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

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.

*