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Consultation

Take this short questionnaire to help us determine if a treatment plan is suitable for you at this time.

Consultations are always anonymous and we do not store your data.

What treatment plan are we assessing you for?

Are you over the age of 18?

Do you currently live in the United Kingdom?

PHQ-9

Read the following questions carefully. Think about how you have been feeling over the past two weeks and answer the questions accordingly.

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

Not
At All
Several
Days
More
Than Half
The Days
Nearly
Every
Day

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

Troubling falling 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 could 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?

Smoking Cessation

Have you ever suffered from clinical depression?

Have you ever been diagnosed as suffering from any other psychological
or psychiatric condition?

Have you ever been diagnosed with or are suffering from the following conditions:
Bipolar Disorder, Schizophrenia, Psychosis?

Have you been diagnosed with any heart conditions?

Have you ever been diagnosed with epilepsy or experienced seizures?

What would you rate your personal level of motivation to stop smoking?

In the past have you continued to smoke during illness (e.g when ill in bed)?

Do you find difficult to refrain from smoking in places where it is forbidden (planes, offices)?

Do you smoke more frequently in the morning?

How many times have you tried to quit smoking in the past?

Do you live with a smoker who is not about to quit?

Are you quitting to please someone else?

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