Online Medication Review Form
As part of our ongoing commitment to your health we undertake an annual medication review on all patients on repeat medication with an ongoing medical conditions. Depending on the types of medication or the specific medical condition you may be asked to have a blood test and a face to face consultation with a doctor, practice pharmacist or specialist practice nurse. Some medication and conditions can be renewed without you needing to visit the surgery.
If you have received a letter please complete the relevant questionnaires which will be reviewed by the clinical team.
Please select... Asthma Chronic Obstructive Pulmonary Disease (COPD) Heart Failure Epilepsy Mental Health Contraception Other Reason for completing this form Full Name Your Address Date of Birth Phone Number Email Address
USAGE OF CURRENT MEDICATION
If not, is there a specific reason or particular medication you struggle with
Do you take any medication not currently prescribed by us here at the practice? This includes any herbal medication i.e. St John's Wart
Please select... No Yes - provided by the hospital Yes - purchased from the pharmacy or health food shop If so, what additional medication do you take? If not, is there a particular tablet you run short of or have in excess? If not, which medication(s) are you unsure about?
How well is your medication working and are you getting any side effects
If not, which medication(s) do you feel are ineffective? If so, which medication(s) and what side effects are you suffering?
THE YEAR AHEAD
Planning your medication for the year ahead
If so, what would you like to change?
Please state who is your preferred pharmacy?