Medication Review

Section

Are you happy for us to contact you by text messaging or email? *

Yes

No

Are you happy to receive test results by text messaging? *

Yes

No

Remember to look at our Wellbeing Centre for more self-help advice.

Named GP (if known):

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

Yes

No

Please specify:

Do you suffer with any side effects that you wish to discuss with your doctor/nurse? *

Yes

No

Do you feel your medical conditions are controlled? *

Yes

No

Do you take your medication regularly? *

Yes

No

Do you know when and how to take your medication? *

Yes

No

Are you happy to continue with your current medications? *

Yes

No

If you are on anti-depressant medication please can you also complete our Mental Health Review form which will give us useful information about how you are getting on and help us decide whether your medication dose needs to be reviewed.
Clicking the link will open the form in a new tab, allowing you to submit this form before starting to complete the Mental Health Review.

Are you taking any other medications that you buy over the counter from the pharmacist directly and that are not on your repeat prescription?

Yes

No

We need to know what these medications are as they could interfere with your repeat medications. Please list them here:

Do you wish to discuss any matters regarding your medications with a doctor or nurse? *

Yes

No

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Are you happy for the doctor to update your review date now? *

Yes

No

Height and Weight

Please provide your height and weight for our records.

Height in centimetres *

Weight in kilograms *

Smoking Review

Do you currently smoke?

Yes

No

Do not currently smoke section

Have you smoked in the past? *

Yes

No

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Do currently smoke section

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? *

Yes

No

Please ask at reception for more information about giving up smoking.

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Total to Audit - C

This is your total score from the first part of the Alcohol Consumption form.

Alcohol Consumption - Part 2

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.

How often during the last year have you found that you were not able to stop drinking once you had started? *

How often during the last year have you failed to do what was normally expected from you because of your drinking? *

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *

How often during the last year have you had a feeling of guilt or remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

No

Yes, but not in the last year

Yes, during the last year

Total to Audit - C - Part 2

This is your total score the Alcohol Consumption form.

Blood Pressure

Please provide a blood pressure reading.

This can be complete at home if you have a blood pressure monitor or you can come into the medical centres hub any time and use the blood pressure monitor.

Heart Rate

Systolic "Higher"

/

Diastolic "Lower"

*

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

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