We are not a crisis service and cannot review your questionnaire immediately. If you feel you cannot keep yourself safe please contact your GP, or call the mental health central access point on 111 and select the mental health option. This free and confidential service is available for anyone of any age across Leicester, Leicestershire and Rutland needing urgent mental health support for themselves or others. Call 999 if there is an immediate risk to your life.

More information about mental health support is available on our website.

Medical psychology assessment questionnaire

Name(Required)
Date of birth(Required)

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

Little interest or pleasure in doing things(Required)
Feeling down, depressed, or hopeless(Required)
Trouble falling or staying asleep, or sleeping too much(Required)
Feeling tired or having little energy(Required)
Poor appetite or overeating(Required)
Feeling bad about yourself — or that you are a failure or have let yourself or your family down(Required)
Trouble concentrating on things, such as reading the newspaper or watching television(Required)
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(Required)
Thoughts that you would be better off dead or of hurting yourself in some way(Required)

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

Feeling nervous, anxious or on edge(Required)
Not being able to stop or control worrying(Required)
Worrying too much about different things(Required)
Trouble relaxing(Required)
Being so restless that it is hard to sit still(Required)
Becoming easily annoyed or irritable(Required)
Feeling afraid as if something awful might happen(Required)

3. People’s problems sometimes affect their ability to do certain day to day tasks in their lives. Look at each question and rate how much your problem impairs your ability to carry out the activity by selecting a number on the scale provided.

(If you are retired or do not work for reasons not related to your problem please select N/A)
(Cleaning, tidying, looking after children)
(With other people, for example, outings, pub)
(For example, gardening, reading, hobbies)
(Form and maintain close relationships with others including the people I live with)
Consent(Required)
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