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Great Park Medical Group

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Opening Hours Please note when Frankley Health Centre is shut, Hollymoor Medical Centre will be open
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New Patients
Appointments
Prescriptions
Services
Patient Record
Health Advice
Online Forms

Home
Language
Opening Hours Please note when Frankley Health Centre is shut, Hollymoor Medical Centre will be open
Our Staff
Online Services
Practice News
Contact Us

Home
Medication Review

Medication Review

Medication Review

Medication Review Online Form

It is important to review your medication regularly to make sure it is appropriate for you.

By having medication reviews we can make sure you are benefiting well from you medication.

Name *

Date of Birth *

Telephone Number *

What prescription Medications do you take on a regular basis *

Are you taking any medicines prescribed by a hospital or clinic *

If yes to the above question please state name of drugs

Do you take any over the counter medicines *

If yes to the above question please state name of drugs

Do you take any recreational drugs *

If yes to the above question please state name of drugs

DO YOU HAVE ANY CONCERNS OR SIDE EFFECTS FROM YOUR MEDICATION *

IF YES TO THE ABOVE QUESTION PLEASE STATE INFO BELOW

DO YOU WHEN AND HOW TO TAKE YOUR MEDICATION *

IF NO TO ABOVE QUESTION PLEASE PROVIDE MOREINFORMATION BELOW

DO YOU NEED ANY HELP FROM A FAMILY MEMBER OR CARER TO REMIND YOU TO TAKE YOUR MEDICINES *

ARE THERE ANY MEDICINES ON YOUR REPEAT PRESCRIPTION LIST THAT YOU DO NOT TAKE, IF YES PLEASE ENTER BELOW

HAVE ANY MEDICINES BEEN STARTED SINCE YOUR LAST MEDICATION REVIEW

HAVE ANY MEDICINES BEEN STOPPED SINCE YOUR LAST MEDICATION REVIEW

DO YOU FEEL YOUR MEDICINES ARE WORKING, IF NO PLEASE PROVIDE INFO BELOW *

PLEASE STATE YOUR SMOKING STATUS *

Current Smoker

Ex Smoker

Never Smoked

E-Cigarettes

IF YOU DO SMOKE, ARE YOU AWARE THAT WE HAVE A TRAINED SMOKING CESSATION NURSES AT THE PRACTICE

YES

NO

NOT APPLICABLE

HOW OFTEN DO YOU DRINK CONTAINING ALCOHOL *

NEVER

MONTHLY OR LESS

2-4 TIMES PER MONTH

2-3 PER WEEK

4+ TIMES A WEEK

HOW MANY UNITS OF ALCOHOL DO YOU DRINK ON A TYPICAL DAY WHEN YOU ARE DRINKING *

NOT APPLICABLE

1-2

3-4

5-6

7-9

10+

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 *

NEVER

LESS THAN MONTHLY

MONTHLY

WEEKLY

DAILY OR ALMOST DAILY

PLEASE TELL US YOUR WEIGHT *

I CONSENT TO THE PRACTICE COLLECTING AND STORING MY DATA FROM THIS FORM *

YES

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Page last reviewed: 29 January 2023
Page created: 15 May 2024

Further Information

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