Looking after your mental health and wellbeing

Your mental health and well-being is important. Please answer these questions as honestly as possible. Your answers will only be viewed by the clinician seeing you at your next appointment.

Please complete this confidential questionnaire prior to your appointment. Thank you.

1

Your mood

Over the last two weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things *
Feeling down, depressed or hopeless *
Trouble falling asleep 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 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. *
If you have had any of these problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Over the last two weeks, how often have you been bothered by the following problems?

Feeling nervous anxious or on edge *
Not being able to stop or control worrying *
Worrying too much about different things *
Trouble relaxing *
Being so restless that it's hard to sit still *
Becoming easily annoyed or irritable *
Feeling afraid as if something awful might happen *
If you have had any of these problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Your drug use

Which, if any, of these drugs have you used during the last year, and how often do you use them?

Cannabis, hash
Cocaine
Crack, freebase
Heroin
Methadone (without a prescription or more than a doctor told you too)
Sedatives/tranquilizers/downers (without a prescription or more than a doctor told you to)
Speed/crystal meth/uppers
Ecstasy, MDMA, M-CAT
LSD, magic mushrooms, hallucinogens
GHB/GBL
Ketamine
Legal highs
I don't use any of the drugs above
Have you ever injected any drugs with a needle ('slammed') ? *
If 'yes', has this happened during the last six months?

Your alcohol use

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 six or more units if female, or eight or more if male, on a single occasion in the last year?

Your memory

Sexual Health Dorset