Medication Online Review form This form can take up to 5 working days to be processed.PLEASE ONLY COMPLETE THIS FORM IF REQUESTED BY THE SURGERYName First Last Date Of Birth DD slash MM slash YYYY Phone NumberEmail Address Usage Of Current MedicationAre you able to take your medication as prescribed every day? Yes No If not, is there a specific reason or particular medication you struggle withDo you understand how and when to take your medication? Yes No Do you take any medication not currently prescribed by us here at the practice? This includes any herbal medication i.e. St John's Wart No Yes – provided by the hospital Yes – purchased from the pharmacy or health food shop If so, what additional medication do you take?Do you get sufficient numbers of tablets each month? Yes No If not, is there a particular tablet you run short of or have in excess?Do you understand why you are taking each medications prescribed? Yes No If not, which medication(s) are you unsure about?EffectivenessHow well is your medication working and are you getting any side effectsDo you feel that your medication is effective? Yes No If not, which medication(s) do you feel are ineffective?Are you suffering any side-effects from any of the medication prescribed? Yes No If so, which medication(s) and what side effects are you suffering?The Year AheadPlanning your medication for the year aheadWould you like to discuss any changes to your medication for the coming year? Yes No If so, what would you like to change?Please state who is your preferred pharmacy?How would you like to order your medication? I will request a repeat prescription from the surgery when required (48 hours notice required) I will ask my preferred pharmacy to request my prescriptions when required (48 hours notice) If possible I would like a years worth of prescriptions sent to my chosen pharmacy (batch prescription) I would like to discuss my medication with the practice pharmacist? Yes – on the phone Yes – face to face No Do you smoke? Never Stopped within the last year Stopped >1 year ago 1-10 per day 11-20 per day 21-30 per day +30 per day Smoking Status Trivial Smoker <1 per day Trying to quit Pipe Smoker Cigar Smoker Vape How much alcohol do you drink? Teetotal 1-10 units per week 11-20 units per week 21-30 units per week +30 units per week Current Weight