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.

Medication Review

If you are human, leave this field blank.

Section

Named GP (if known):

Smoking Review

Smoking Status: *

Never Smoked

Ex-Smoker

Current Smoker

How many cigarettes a day? *

If yes, would you like us to refer you to Smoking Cessation: *

Yes

No

Do not currently smoke section

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Please state the month and year that you last smoked: *

Blood Pressure

Systolic "Higher"

/

Diastolic "Lower"

Height

Feet: *

Inches: *

Weight

Stone: *

Lbs: *

Pulse:

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? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your 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

Are you a carer for a friend or member of your family? *

Yes

No

Have you ever been a member of the armed forces? *

Yes

No

Please check your medication list (right hand side of your prescription). Is it accurate? *

Yes

No

Please inform us if there are any medication you feel are missing or are no longer taken. *

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

Yes

No

If so, what? *

Do you normally have a batch prescription?

Yes

No

If no, would you like a batch prescription? *

Yes

No

Are you on medication for asthma? *

Yes

No

If yes, please complete our asthma review form online.

Are you on medication for a mental health condition such as depression/anxiety? *

Yes

No

If yes, please book a telephone appointment with your GP

Are you on contraception? *

Yes

No

If yes, please complete the contraception review form online.

Are you on medication for high blood pressure, ischemic heart disease or because you have had a stroke? *

Yes

No

*

I have answered the above questions to the best of my knowledge and am aware of the risks to my health if the information provided here is inaccurate

*

I am requesting this medication for my sole use only and not on the behalf of another person

Submit