Medication review

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Named GP (if known):

Do you know the names of your medication? Required

Yes

No

Please list the names of your medication: Required

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.

Blood Pressure Reading

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? Required

Yes

No

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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Blood Pressure Reading