Medication Review

We regularly review any regular medication on a repeat prescription and wherever possible the doctor or our Clinical Pharmacist will do this without you having to attend the surgery.

If your medication review is due, please complete and submit this form.  This will be reviewed and if any further action is needed we will contact you.

Please note that submission of this review does not automatically mean your medication will be updated and ordered for you. You will still need to order your medication as you would normally do.

Medication Review Form

Medication Review Form

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Do you remember to take your medication? *
Do you take all your medication as prescribed? *
Do you have any concerns or side effects from your medication? *
Do you know when and how to take your medication? *

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

Do you have any allergies? *
Do you smoke? *
Would you like advice to quit? *
Do you measure your Blood Pressure at home? *

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/
*