Pre-consultation: Depression & Anxiety

First name *

Last name *

Email *

Phone *

Date of birth *

Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had trouble falling or staying asleep, or sleeping too much? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt tired or had little energy? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had a poor appetite or been overeating? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt bad about yourself, or that you are a failure? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had trouble concentrating on things? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been moving or speaking so slowly that others have noticed? Or been so fidgety or restless that you have been moving around a lot more than usual? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself? *

SAFETY QUESTION: If answering 'Several days' or more, additional support will be discussed.

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt nervous, anxious, or on edge? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been unable to stop or control worrying? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you worried too much about different things? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had trouble relaxing? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been so restless that it is hard to sit still? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you become easily annoyed or irritable? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt afraid as if something awful might happen? *

Not at all

Several days

More than half the days

Nearly every day

Do you experience panic attacks (sudden episodes of intense fear with physical symptoms)? *

No

Yes

Do you experience social anxiety (fear of social situations or being judged)? *

No

Yes

Do you experience obsessive-compulsive symptoms (unwanted intrusive thoughts with repetitive behaviors)? *

No

Yes

Do you experience health anxiety (persistent worry about having a serious illness)? *

No

Yes

Do you have a history of trauma or symptoms related to a traumatic event (PTSD)? *

No

Yes

What sleep difficulty best describes your experience? *

No difficulty

Trouble falling asleep

Waking during the night

Early morning waking

Nightmares

Sleeping too much

On average, how many hours of sleep do you get per night? *

How would you rate your sleep quality? *

Very poor

Poor

Fair

Good

Excellent

What is the main trigger or stressor for your current mood? *

How long have you been experiencing your current symptoms? *

Less than 2 weeks

2-4 weeks

1-3 months

3-6 months

More than 6 months

More than a year

How much is depression/anxiety affecting your daily functioning? *

Not at all

Mildly

Moderately

Severely

Extremely (unable to function)

Is this the first time you have experienced depression or significant anxiety? *

No

Yes

Have you previously had therapy or counselling? *

No

Yes

Have you previously taken medication for depression or anxiety? *

No

Yes

How would you describe your alcohol use? *

None

Social only

Regular (a few times a week)

Heavy (daily or most days)

Using alcohol to cope with mood symptoms

Do you use recreational drugs? *

No

Yes

How many cups of caffeine do you consume per day? *

Are you currently taking any medications? *

No

Yes

Have you ever deliberately harmed yourself? *

No

Yes, in the past

Yes, currently

Have you had thoughts of ending your life, or do you have a plan to harm yourself?

SAFETY QUESTION. If you are in immediate danger, please call 999 or go to your nearest A&E. Crisis support: 116 123 (Samaritans).

No

Yes

Do you have access to means to carry out harm (e.g. medications, methods)?

No

Yes

Unsure

Do you have factors that protect you from suicide (e.g. family, work, friends, pets, future plans)?

No

Some

Yes, strong protective factors

What are you hoping to get from this consultation? *

Diagnosis

Medication

Therapy referral

Medication review

Crisis support

General advice and support

Is there anything else you'd like us to know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Depression Screening (PHQ-9)

Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things? -

Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? -

Over the last 2 weeks, how often have you had trouble falling or staying asleep, or sleeping too much? -

Over the last 2 weeks, how often have you felt tired or had little energy? -

Over the last 2 weeks, how often have you had a poor appetite or been overeating? -

Over the last 2 weeks, how often have you felt bad about yourself, or that you are a failure? -

Over the last 2 weeks, how often have you had trouble concentrating on things? -

Over the last 2 weeks, how often have you been moving or speaking so slowly that others have noticed? Or been so fidgety or restless that you have been moving around a lot more than usual? -

Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself? -

Anxiety Screening (GAD-7)

Over the last 2 weeks, how often have you felt nervous, anxious, or on edge? -

Over the last 2 weeks, how often have you been unable to stop or control worrying? -

Over the last 2 weeks, how often have you worried too much about different things? -

Over the last 2 weeks, how often have you had trouble relaxing? -

Over the last 2 weeks, how often have you been so restless that it is hard to sit still? -

Over the last 2 weeks, how often have you become easily annoyed or irritable? -

Over the last 2 weeks, how often have you felt afraid as if something awful might happen? -

Types of Anxiety

Do you experience panic attacks (sudden episodes of intense fear with physical symptoms)? -

Do you experience social anxiety (fear of social situations or being judged)? -

Do you experience obsessive-compulsive symptoms (unwanted intrusive thoughts with repetitive behaviors)? -

Do you experience health anxiety (persistent worry about having a serious illness)? -

Do you have a history of trauma or symptoms related to a traumatic event (PTSD)? -

Sleep Pattern

What sleep difficulty best describes your experience? -

On average, how many hours of sleep do you get per night? -

How would you rate your sleep quality? -

Current Symptoms & Triggers

What is the main trigger or stressor for your current mood? -

How long have you been experiencing your current symptoms? -

How much is depression/anxiety affecting your daily functioning? -

Previous Episodes & Treatment History

Is this the first time you have experienced depression or significant anxiety? -

Have you previously had therapy or counselling? -

Have you previously taken medication for depression or anxiety? -

Substance Use & Self-medication

How would you describe your alcohol use? -

Do you use recreational drugs? -

How many cups of caffeine do you consume per day? -

Current Medications

Are you currently taking any medications? -

Safety Assessment

Have you ever deliberately harmed yourself? -

Have you had thoughts of ending your life, or do you have a plan to harm yourself? -

Do you have access to means to carry out harm (e.g. medications, methods)? -

Do you have factors that protect you from suicide (e.g. family, work, friends, pets, future plans)? -

What You're Hoping For

What are you hoping to get from this consultation? -

Is there anything else you'd like us to know? -

Anything else for your doctor?