Medication Review

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Concordance: Do you understand the purpose of each medication?

Yes – No further discussion or support is required

Yes – and I would like to discuss the purpose of my medication with a clinician

If No, please explain

Compliance: Are you able to take your medication as directed on the labels?

Yes – No further discussion or support is required

Yes – and I would like to discuss my medication compliance with a clinician

If No, please explain

Efficacy: Are your medicines effective in controlling your symptoms?

Yes

No – No further discussion or support is required

No – and I would like to discuss efficacy with a clinician

If No, please explain

Side Effects: Have you experienced any side effects which may be attributable to your medication?

Yes – No further discussion or support is required

Yes – and I would like to discuss these side effects with a clinician

If Yes, please explain

Using your medicines: Do you have any problems which, if addressed, would assist you in taking your medication?

Yes – No further discussion or support is required

Yes – and I would like to discuss these problems with a clinician

If Yes, please explain

Reduce wastage: Have you stopped taking any medication and can these be removed from your repeat list?

Yes – No further discussion or support is required

Yes – and I would like to discuss this with a clinician

If yes, please explain

Privacy Policy

Your consent *

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

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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