Medication Review

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Who are you submitting this request for?

What is your relationship to the patient? OptionalPlease answer this section if you are completing the form on behalf of someone.

About you (The patient)

Name

First Last

Date of Birth

DD slash MM slash YYYY

Mobile

Address

Street Address Address Line 2 City County / State / Region Postcode Country

What is your sex assigned at birth?

Female

Male

Are you taking more than five medicines on a regular basis?This includes all your tablets, patches, sprays, inhalers, creams, liquids and eye drops.

Yes

What prescription medicines do you take on a regular basis (daily, weekly or monthly)?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?

Yes

Which of your current medicines are prescribed by a hospital or another clinic? OptionalPlease answer if you answered YES to the above question.

Do you understand what each one of your prescribed medicines is for?

Yes

What do you understand about your prescription medicines?Please also state what you do NOT understand about your medication.

Do you understand when to take your medicines?

Yes

Are there any medicines on your repeat prescription list that you do not take?

Yes

Which medicines do you not take and why? OptionalPlease answer the question if you answered YES to the above question.

Have any medicines been started since your last medication review?

Yes

Which medicines have been started since your last review? OptionalPlease answer the question if you answered YES to the above question.

Have any medicines been stopped since your last review?

Yes

Which medicines have been stopped since your last review? OptionalPlease 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?For example, a higher or lower dose.

Yes

Which medicines have had a dosage change and was the change to a higher or lower dose? OptionalPlease answer the question if you answered YES to the above question.

Do you feel all your medicines are working for you? Yes

Yes

I don't know

Do you get any side effects from your medicines?

Yes

I don't know

What side effects do you feel? OptionalPlease answer the question if you answered YES to the above question.

Do you find it easy to take your medicines?For 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?

Yes

What do you find difficult about taking your medicines? OptionalPlease answer the question if you answered YES to the above question.

Do you ever forget to take any of your medicines?

Yes, most of the time

Yes, some of the time

Occasionally

Never

Which medicines do you tend to forget to take? OptionalPlease 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?

Yes

Do you have any problems ordering your medicines?

Yes

What problems do you have when ordering your medicines? OptionalPlease answer the question if you answered YES to the above question.

Which pharmacy do you like to use for your repeat prescriptions?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)?You can nominate your pharmacy or change your pharmacy using the NHS app. You can also order repeat prescriptions through the NHS app.

Yes

I don't know

Do you take any over-the-counter medicines?This includes medicines like painkillers, antihistamines, vitamins and supplements.

Yes

I don't know

What over-the-counter medicines do you take? OptionalPlease answer the question if you answered YES to the above question.

Do you take any complementary, Chinese or herbal medicines?

Yes

What complementary, Chinese or herbal medicines do you take? OptionalPlease answer the question if you answered YES to the above question.

Do you get any medicines from the Internet or from another country?

Yes

What medicines do you get from the Internet or another country? OptionalPlease answer the question if you answered YES to the above question.

Do you use any recreational drugs?

Yes

What recreational drugs do you use and how often? OptionalPlease 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.

Tell us your weightPlease indicate whether in kg or stones.

Tell us your height OptionalPlease indicate whether in cm or feet.

Do you know your blood pressure reading from the last month?

Yes

No, but I have had my blood pressure measured at the surgery/pharmacy

Please provide your blood pressure reading with your systolic (upper) and diastolic (lower) valuesFor example: 120/80

Have you had any blood tests taken in the last month?

Yes

Where did you have your blood tests taken? OptionalPlease 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?

Yes

What else would you like to tell us? OptionalPlease answer the question if you answered YES to the above question.

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ImportantImportant

Medication Review

Medication Review.

About you (The patient)

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

Additional Information