Medication Review

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

If you have been advised by the surgery that your medication review is due, please use this form.

If you are due a review of your contraceptive pill, please visit Contraception instead.

Please be aware that once this form has been submitted, it will be held within your health record.

Medication Review

Medication Review

Section

Does this review concern all of your medication? *
Are there any concerns or side effects from the medication? *
Do you know when and how to take your medication? *
Do you smoke?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Please contact SmokeFree Norfolk for help quitting (Opens in new tab)

Have you smoked in the past?
How many cigarettes did you smoke in a day?
Only answer this question if you have weighed yourself. Please do not guess.

If you have a home blood pressure monitor, please can you provide a blood pressure reading (optional):

/
Do you take medication for your mental health? *

Do you remember to take your medication every day? *
Have there been any significant changes in your life since we last discussed your mental health? *
Do you think your mental health is getting better, getting worse, or staying the same? *
Do you have any problems sleeping? *

For immediate help

This is not an emergency form. If you require immediate help or are considering self harm, you can seek help and advice today by visiting 111.nhs.uk or calling 111, or the crisis team on 0808 196 3494.

Do you take any recreational drugs? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Next Steps

What would you like the practice to do now? *

The practice will contact you if we need to discuss your medication.

How would you prefer us to contact you? *

If you need your medication issued now, please request it in the usual way.

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