Medication Review Form

Form to be used by patients when requested to review medications that have reached their maximum number of issues

Last Updated: 15/12/2021

Conditions of use:

This form is for the safe and efficient management of repeat prescriptions ONLY. This form should only be used when directed to do so by a member of the prescription management team. Any other requests made on this form will be ignored. *

I confirm that I have read the conditions of use

Your details.

Forename *

Surname *

Date of Birth *

Mobile Phone Number *

Email address

Height *

Weight *

Approximately how many units of alcohol do you drink each day? *

More than 9 units/day

7-9 units/day

3-6 units/day

1-2 units/day

less than 1 unit/day

I am teetotal

Smoking

Are you a current smoker? *

Yes No

If you are a current smoker, do you smoke

Cigarettes

Cigars

Pipe

Electronic Cigarettes

Other

How many do you smoke a day?

Are you an Ex Smoker? *

Yes No

If you answered yes to the question above please state when you successfully stopped smoking

Blood Pressure

If you have a blood pressure machine, please enter your blood pressure below

If you have a blood pressure monitor please enter your pulse below

Please complete the following questions for all your medications

Are you taking all the medications on your repeat slip? *

Yes No

Do you still need all of the medications you are prescribed? *

Yes No

Would you like to stop/ reduce the dose of any of your medications? *

Yes No

If you answered yes to the question above please tell us which medications you would like to stop and why.

Side Effects

If you choose YES for the following question you should not submit this form. You should make a telephone medication review appointment and for safety reasons your repeat will not be updated until you have done so.

Are you having any side effects which you need to discuss with the Gp *

Yes No

Medication Update

If you choose NO for the following question you should not submit this form. You should make a telephone medication review appointment and for safety reasons your repeat will not be updated until you have done so.

Are you happy for the GP to renew your medications as above? *

Yes No

Consent

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, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form

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Medication Review Form

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