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Temporary Services
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
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Home
About Us
Contact
Contact Telephone Numbers
Friends & Family Test
Location
Letter Request
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Send a Message
Have your Say
Compliments and Suggestions
Friends and Family Test
Complaints
Patient Opinion
Patient Participation Group
Making the most of your Practice
Opening Hours
What to do when we are closed
Our Team
Practice Policies
At the Practice
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding Children
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Newham Access 7 Days a week service
Help with your GP Appointment
Hospital Appointments – Book, Cancel or Change
NHS 111 online – Get Help for your Symptoms
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access Your Test Results
Other Common Tests
Urine Tests
X-Rays & Scans
What is a Blood Test?
Who Do I See?
Clinics & Services
Clinics
Antenatal Care
Child Health Checks
Clinics we provide
Long Term Conditions
NHS Health Check aged 40 – 74
Travel Clinic & Holiday Vaccinations
Online Services
Register for Online Services
NHS App
Practice Services
Advocacy Service
Audiology & Hearing in the Community
Dementia Services
Cervical Screening
Diabetes Services
Hepatitis B Immunisation
Register with us as a New Patient
Further Help about how to Register with a GP
Registration Policy
Temporary Services
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
Non NHS Services – Chargeable
Order a Repeat Prescription
Antibiotic Use
Wasted Medications
Electronic Prescriptions
Patient Transport Service
Sick/Fit Note
The Rapid Response Team
Texting Service
Forms
Keep us up to Date
Change of Contact Details Form
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Communication Consent Form
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
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The Vicarage Lane Surgery
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Health Review Forms
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Mental Health Review (PHQ-9) Form
Mental Health Review (PHQ-9) Form
Mental Health Review (PHQ-9)
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Mental Health Review
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless?
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much?
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy?
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating?
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television?
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
*
Not at all
Several days
More than half the days
Nearly every day
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not at all
Several days
More than half the days
Nearly every day
PHQ-9 Score
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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