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Introduction

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Personal Details
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Assessment

Answer the questions below. For each one, indicate on a scale of 1 to 5 how much of a problem it is for you where 1 is not a problem and 5 is a big problem.

Being tired/no energy/fatigue: *
Stress and worry: *
Feeling low or tearful: *
Shortness of breath: *
Pain: *
Sleep problems: *
Managing to work: *
Money/benefits: *
Housing/where you live: *
Family/friends/relationships: *
Having children: *
Support from the NHS: *
Learning about your condition: *
Being able to relax: *
Doing exercise: *
Walking/climbing stairs: *
Getting out and about, doing things you enjoy: *
Sexual problems: *
Eating a healthy diet: *
Stopping smoking: *
Manging your medicines: *
Measuring your symptoms at home: *
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Feeling low

Over the last 2 weeks have you been bothered by these problems?

Feeling nervous, anxious or on edge: *
Not being able to stop or control worrying?: *
Feeling down, depressed or hopeless?: *
Little or no pleasure in doing things?: *
The thought of harming myself has occurred to me: *
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Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Care Quality Commission
Rating: Good

Stamford Hill Group Practice
2 Egerton Road
London
N16 6UA

Telephone: 020 8800 1000