General Practice Physical Activity Questionnaire

Welcome to your MH Questionnaire

Name and surname

Age

Your address

Telephone number

Email

Ethnicity

Gender

Nationality

What area of mental health do you want to improve (tick as many as it applies)

Please mark one box only

Depression

Anxiety

Family issues

Loneliness

Obesity

Eating Disorder

Stress

Grief

Self-esteem

Other

Have you been referred to a specialist in the past?

Yes

No

I prefer not to answer

Do you suffer from suicidal thoughts?

Yes

No

I prefer not to answer

Has your condition worsen due to COVID19 and the self-isolation measures?

Yes

No

I prefer not to answer

Are you in interested in:

One to one session

Group session

Please fill in the comment box below.