Mental Health Assessment Form

Section

General Health and Wellbeing

Smoking status:
I would be helpful if you could tell us the following information, but we understand you may not be able to answer all the below questions:
You may benefit from some lifestyle advice with regards to your weight management, please visit the Wellbeing Centre for more information.

Care

Are you already under the care of a psychiatrist or mental health worker?
Do you have a carer?
Do you have a lasting power of attorney in place?

Review

Current Mood:
Anxiety Levels:
Sleep Pattern:
Hallucinations:
Paranoia:
Delusions:
Thoughts:
Behavoiours:

Can you recognise potential stressors?

Stress levels:
Housing:
Employment:

Care Plan

Do you have a psychiatric care plan in place?

Medication

Are you on any medication supplied by mental health?
Are you routinely taking this medication?
Do you have any side effects?
If you are on injectable medication, who is administering them?

Drug Use

Are you currently using any illicit drugs? This information will not be passed on, but is important for your quality of care.