The Allan Practice
Mental Health Review
Last Updated: 14/08/2020
Date of birth
How many units of alcohol do you drink each week?
Do you consider your diet to be healthy?
Do you take part in exercise / physical activity?
Do you use recreational or non-prescription drugs (e.g. cannabis)? If yes, what do you use?
Do you smoke?
Trivial (less than one cigarette per day)
Light (1-9 cigarettes per day)
Moderate (10-19 cigarettes per day)
Heavy (20-39 cigarettes per day)
Very heavy (40+ cigarettes per day)
Rolls own cigarettes
Smokes a pipe
Please enter your current weight.
Please enter your most recent blood pressure reading if known.
Are you currently under the care of the mental health department?
Do you have an allocated community psychiatric nurse, care coordinator or social worker?
Do you currently work? This can include paid or volunteer positions you hold.
Do you have any problems with your medication/s?
Questions or concerns
Do you have any questions or concerns?
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