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.

Please do not use this form to order repeat prescriptions.

Medication Review

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Named GP (if known):

Do you have any concerns or side effects from your medication?

Yes

No

Please specify:

Do you know when and how to take your medication?

Yes

No

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Are you happy for the doctor to update your review date now?

Yes

No

Smoking Review

Do you currently smoke?

Yes

No

Do not currently smoke section

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Do currently smoke section

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Please ask at reception for more information about giving up smoking.

Alcohol Consumption

This is one unit of alcohol:

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

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

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

Total to Audit - C

This is your total score from the first part of the Alcohol Consumption form.

Alcohol Consumption - Part 2

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.

How often during the last year have you found that you were not able to stop drinking once you had started? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking? *

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

No

Yes, but not in the last year

Yes, during the last year

Total to Audit - C - Part 2

This is your total score the Alcohol Consumption form.

*

I confirm that the information provided is accurate to the best of my knowledge

*

I confirm that I have no urgent or serious concerns about my medication