Medication Review

Medication Review.

Please note that this review will be asking for your blood pressure, height and weight.

Please answer this section if you are completing the form on behalf of someone.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required

About Your Medication

Are you taking more than five medicines on a regular basis?  RequiredThis includes all your tablets, patches, sprays, inhalers, creams, liquids and eye drops.
Please list your medicines and how often you take them, even if this is different to how your GP prescribes the medicines.
Are you taking any medicines prescribed by a hospital or another clinic?  Required
Please answer if you answered YES to the above question.
Do you understand what each one of your prescribed medicines is for?  Required
Please also state what you do NOT understand about your medication.
Do you understand when to take your medicines?  Required
Are there any medicines on your repeat prescription list that you do not take?  Required
Please answer the question if you answered YES to the above question.
Have any medicines been started since your last medication review?  Required
Please answer the question if you answered YES to the above question.
Have any medicines been stopped since your last review?  Required
Please answer the question if you answered YES to the above question.
Have any of your medicines had a dosage change since your last medication review?  RequiredFor example, a higher or lower dose.
Please answer the question if you answered YES to the above question.
Do you feel all your medicines are working for you? Yes  Required
Do you get any side effects from your medicines?  Required
Please answer the question if you answered YES to the above question.
Do you find it easy to take your medicines?  RequiredFor example, are your tablets easy to swallow? Can you open the packaging without difficulty? Can you fit your medicines around your meals and daily life? Do you know how to use your inhalers or sprays?
Please answer the question if you answered YES to the above question.
Do you ever forget to take any of your medicines?  Required
Please answer the question if you answered YES to the above question.
Do you need help from a family member, partner or carer to prompt you to take your medicines?  Required
Do you have any problems ordering your medicines?  Required
Please answer the question if you answered YES to the above question.
Please add the pharmacy name and address so that we can check that your records are up to date.
Have you set up a nominated pharmacy to receive electronic prescriptions (EPS)?  RequiredYou can nominate your pharmacy or change your pharmacy using the NHS app. You can also order repeat prescriptions through the NHS app.
Do you take any over-the-counter medicines?  RequiredThis includes medicines like painkillers, antihistamines, vitamins and supplements.
Please answer the question if you answered YES to the above question.
Do you take any complementary, Chinese or herbal medicines?  Required
Please answer the question if you answered YES to the above question.
Do you get any medicines from the Internet or from another country?  Required
Please answer the question if you answered YES to the above question.
Do you use any recreational drugs?  Required
Please answer the question if you answered YES to the above question.

Tell us your height and weight so we can calculate your Body Mass Index (BMI). Please also provide some blood pressure readings.

Please indicate whether in kg or stones.
Please indicate whether in cm or feet.
Do you know your blood pressure reading from the last month?  Required
For example: 120/80
Have you had any blood tests taken in the last month?  Required
Please answer the question if you answered YES to the above question.
Is there anything else you would like to tell us that we have not asked?  Required
Please answer the question if you answered YES to the above question.
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Additional Information

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