Medication Review

Please complete this form when your medication review is due. We will let you know if you require a blood test

Last Updated: 03/05/2023

Your Details

Full Name

Date of Birth

Mobile Number

Email Address

Height, in cms (optional)

Weight, in kg (optional)

Blood pressure, this could be an average reading & if so please state number of readings taken (optional)

Pulse (Heart rate) at rest (optional)

What is your smoking status?

Stopping smoking

Units of alcohol each week (optional)

If more than 14 units/week we suggest cutting down (optional)

Do you have a parent or sibling who has had a heart attack or angina under the age of 60 (optional)

Ethnic Group
Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION & MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU & ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA

I consent to the practice collecting and storing my data from this form

Yes

I consent to the practice sending me text messages concerning my direct medical care & practice information

Yes

No

I consent to the practice sending me emails concerning my direct medical care & practice information (optional)

Yes

No
Medication Review

Do you understand the reason why you are taking each of your medications? If not please state which medications you are unsure about

Do you understand how to take each of your medications? If not then please list the medications you are unsure about

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)

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

Do you ever forget to take your medication, if so which one(s) & how often?

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

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

Please list any medications you feel you no longer need (E.g. for pain/symptom relief) (optional)

Do you have any other concerns relating to any of your medications?

Do you have any known drug allergies?

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Medication Review

Your Details

Consent

Medication Review