Medication Review Assessment Form

Name *

Date of Birth *

Telephone Number *

Email Address

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

Yes No

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

Yes No

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

Yes No

Is there any medication you are able to reduce or stop at this moment in time? *

Smoking Status - please select as below: *

Smoker

Ex Smoker

Never Smoked

If you have answered Smoker to the above question, how many cigarettes do you smoke daily?

1 to 9

10 to 19

20 to 39

40 or more

Would you like advice on giving up smoking? *

Yes

No

Not Applicable

Please provide details of any recent tests, for example blood pressure readings, or recent blood monitoring (if using your own machines at home). You do not need to include details of tests done at the surgery.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, allow the practice team to contact you and to update your medical records. Please read our Privacy Policy to discover how we protect and manage your submitted data. Are you happy for the surgery to use your details and answers to this questionnaire? *

Yes No

MEDICATION REVIEW ASSESSMENT FORM

Further Information