Medication Review

We review any regular medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due, please use this form.

Medication Review

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Phone Number: *

Email Address: *

Any responses we send will go to this email address.

Named GP (if known):

Do you have any concerns or side effects from your medication?

Yes

No

Please specify:

Do you understand the reason why you are taking each of your medications?

Yes

No

Which medications are you unsure as to why they have been prescribed?

Do you understand how to take each of your medications?

Yes

No

Please list the medications you are unsure how to take:

Do you find it easy to take each of your medications? (For example, you are able to press the canister down on your inhaler or you can easily swallow the tablets)

Yes

No

Please describe the difficulties or barriers in taking your medication:

Are you currently taking each of your medications as they are prescribed on the label?

Yes

No

Sometimes

Which of your medications are you taking differently to how they were prescribed?

It is sometimes difficult to remember to take medication. At times do you forget to take any of your medications?

Yes

No

Sometimes

Please list the medications which you might sometimes forget to take:

Do you get any side effects from the medication you are taking?

Yes

No

Please list these medications and any side effects you may be experiencing from them

If you take any other medications (including supplements or herbal remedies) that have not been prescribed, please list them:

Do you manage your own medication? (Rather than, for example, a family member, friend or carer managing your medications?)

Yes

No

Please list any medications on your repeat list you feel you no longer need:

What is your smoking status?

Current smoker

Ex smoker

Never smoked

How much do you smoke?

Less than 1 cigarette or equivalent per day

1 to 9 cigarettes or equivalent per day

10 to 19 cigarettes or equivalent per day

20 to 39 cigarettes or equivalent per day

40 or more cigarettes or equivalent per day

How much did you smoke?

Less than 1 cigarette or equivalent per day

1 to 9 cigarettes or equivalent per day

10 to 19 cigarettes or equivalent per day

20 to 39 cigarettes or equivalent per day

40 or more cigarettes or equivalent per day

How many years did you smoke for?

Are you able to provide a blood pressure reading? (As part of a medication review, it is useful to have an up-to-date blood pressure reading)

Yes

No

Blood Pressure Reading

Date of reading:

Please use this date format: DD/MM/YYYY

Systolic (Higher):

Diastolic (Lower):

Heart Rate:

Are you happy for our doctor or pharmacist to update your review date now?

Yes

No

*

I confirm that the information provided is accurate to the best of my knowledge