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.

Please be aware that any replies from the surgery may appear in your junk inbox.

Medication Review

Medication Review

Section

Does this review concern all of your medication? *

Review

Are there any concerns or side effects from the medication? *
Do you know when and how to take your medication? *

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

Do you smoke?
If you have a home blood pressure monitor, please can you provide a blood pressure reading:
/
Are you happy for the clinician to update your review date now? *
Do you need this medication issuing?
Do you take medication for your mental health?

Mental Health Questions

Do you remember to take your medication every day?
Do you have any side effects with the medication?
Have there been any significant changes in your life since we last discussed your mental health?
Do you think you are improving, deteriorating or staying the same?
Do you have any problems sleeping?

For immediate help

This is not an emergency form. If you require immediate help or are considering self harm, you can seek help and advice today by visiting 111.nhs.uk or calling 111 and selecting option 2.

Mental Health Questions Continued

Do you take any recreational drugs?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

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

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
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?

If your score is less than 5

A score of less than 5 may indicate that you do not have a higher risk of drinking.

A score of 5 or more

A score of 5 or more may indicate increasing or higher risk of drinking. Please send this assessment to your GP by completing your details below and then press submit.

Alcohol Consumption Continued

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? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *
*