Medication review

Named GP (if known):

Do you know the names of your medication? *

Yes

No

Please list the names of your medication: *

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

Yes

No

Please specify:

Do you know when and how to take your medication?

Yes

No

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Please provide us with a blood pressure reading below.

We have a blood pressure machine in each practice waiting room if you do not have access to a blood pressure machine.

Systolic (Higher):

Diastolic (Lower):

Heart Rate:

Height:

Weight:

Do you feel you need any change to your medication? *

Yes

No

Please specify:

What is your smoking status?

Smoker

Never smoked

Ex-smoker

Are you happy for the doctor to update your review date now?

Yes

No

I confirm that the information provided is accurate to the best of my knowledge

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