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Medication Review

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Medication Review Form

Submit appointment request

Medication Review Form

Required fields are marked with an asterisk (*).

Your contact details

Name

First

Last

Date of Birth*

Email address*

Phone Number*

Medication review questionnaire

1. Are you happy for this medication review to be completed using your medical records and the information you provide today if no concerns are identified?*

Yes

No

2. Do you understand what each of your prescribed medicines is for?*

Yes

No

3. Do you take your medicines as prescribed?*

Always

Most of the time

Sometimes

Rarely

4. If you miss doses, what is the main reason?*

I forgot

Side effects

I do not think I need them

Difficulty swallowing

Packaging is difficult to use

Other

5. Have you stopped, reduced or changed the dose of any medication without advice from a healthcare professional?*

Yes

No

If, yes please provide details

6. Do you feel your medicines are working as intended?*

Yes

No

7. Are there any medicines you would like to discuss, reduce or stop?*

Yes

No

If, yes please provide details

8. Have you experienced any side effects or concerns from your medicines?*

Yes

No

If, yes please provide details

9. Have you had any falls, blackouts, dizziness or balance problems in the last 12 months?*

Yes

No

If, yes please provide details

10. Have you attended A&E, been admitted to hospital, or seen a specialist because of a medication-related issue in the last 12 months?*

Yes

No

If, yes please provide details

11. Do you take any over-the-counter medicines purchased from a pharmacy, supermarket or online?*

Yes

No

If, yes please provide details

12. Do you take any vitamins, supplements or herbal remedies?*

Yes

No

If, yes please provide details

13. Have you started any new medicines from a hospital specialist or another healthcare provider since your last review?*

Yes

No

If, yes please provide details

14. Do you have any allergies or previous reactions to medicines?*

Yes

No

If, yes please provide details

15. Do you monitor your blood pressure at home?*

Yes

No

Website URL*

If, yes please provide details

16. Please provide your current weight (if known).

17. Do you currently smoke?*

Yes

No

Former smoker

18. How many units of alcohol do you drink each week?*

None

1-14 units

More than 14 units

19. Do you require any support with managing your medicines?*

Yes

No

20. Does someone help you manage your medicines?*

Yes

No

If, yes please provide details

21. Do you have any communication needs or reasonable adjustment requirements?

Hearing impairment

Requires interpreter

Carer involvement

Other

22. Is there anything else you would like the pharmacist to know about your medicines or health?

Privacy Consent – This form collects personal and medical information about you/ We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage submitted data.

I consent to the practice collecting and storing my data from this form

Are you human?*

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More medication review forms

Antidepressant medication review

Contraceptive review

HRT review form

Self-referral forms

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Shifnal & Priorslee Medical Practice

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01952 460 414

Haughton Road, Shifnal, Shropshire, TF11 8DD

Gatcombe Way, Priorslee, Telford, TF2 9GZ

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