In an emergency call 999. Out-of-hours call 111. Askern Medical Practice: 01709 514443
Askern Medical Practice NHS general practice
Join us
Askern Medical Practice

Depression questionnaire

Complete this form and our team will process your request. We aim to respond within 2 working days.

This form is not for urgent problems. If you need help today, phone the practice on 01709 514443. In an emergency call 999.

If you are in crisis or having thoughts of harming yourself, do not wait for this form to be read: call 999, or call 111 and select the mental health option, or call the Samaritans free on 116 123, any time.

Name
Home Address
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed(Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual)
Thoughts that you would be better off dead, or of hurting yourself in some way
The problems I've checked off above…

By sending this form you agree to the practice using the information above to process your request. See our privacy policy.