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May Lane Surgery NHS GP Surgery in Dursley

Medication review

Medication Review

Section

Do you understand the reason why you are taking each of your medications?

Yes

No

Which medications are you unsure as to why they have been prescribed? *

Do you understand how to take each of your medications?

Yes

No

Please list the medications you are unsure how to take: *

Do you find it easy to take each of your medications?

Yes

No

(For example, you are able to press the canister down on your inhaler or you can easily swallow the tablets)

Please describe the difficulties or barriers in taking your medication *

Are you currently taking each of your medications as they are prescribed on the label?

Yes

No

Sometimes

Which of your medications are you taking differently to how they were prescribed? *

It is sometimes difficult to remember to take medication. At times do you forget to take any of your medications?

Yes

No

Sometimes

Please list the medications which you might sometimes forget to take: *

Do you get any side effects from the medication you are taking?

Yes

No

Please list these medications and any side effects you may be experiencing from them: *

If you take any other medications (including supplements or herbal remedies) that have not been prescribed, please list them here:

Do you manage your own medication?

Yes

No

(Rather than, for example, a family member, friend or carer managing your medications?)

Please list any medications you feel you no longer need:

What is your smoking status?

Current Smoker

Ex-smoker

Never Smoked

How much do you smoke?

Under 1 cigarette or equivalent per day

1-9 cigarettes or equivalent per day

10-19 cigarettes or equivalent per day

20-39 cigarettes or equivalent per day

40+ cigarettes or equivalent per day

How many years have you smoked for?

How much did you smoke?

Under 1 cigarette or equivalent per day

1-9 cigarettes or equivalent per day

10-19 cigarettes or equivalent per day

20-39 cigarettes or equivalent per day

40+ cigarettes or equivalent per day

How many years did you smoke for?

Are you able to provide a weight and height reading?

Yes, both

Weight Only

Height Only

No

Please enter your weight in kilograms:

Please enter your height in metres:

Are you able to provide a blood pressure reading?

Yes

No

(As part of a medication review, it is useful to have an up-to-date blood pressure reading)

Blood Pressure Reading

Date of reading:

Please use this date format: DD/MM/YYYY

Systolic (Higher):

Diastolic (Lower):

Heart Rate:

Further Information

Do you have any other concerns relating to any of your medications?

*

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

If you are human, leave this field blank.

Sending

May Lane Surgery
Dursley
Gloucestershire
GL11 4JN

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01453 540555

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