Medication Review

If you have been advised by the surgery to complete a questionnaire as part of a medication review, please use this form.

Please complete what you can. A clinician may follow up your responses with an appointment or phone call if they feel it is needed. If you are unsure of any sections or have answers that do not have an option, please add these to the additional information section at the end.

Medication Review

Medication Review


Do you understand why you have been prescribed your medication and what it is for?
Do you take your medication the correct way as stated on the label?
Are any of the medications you are currently prescribed causing you any problems?
Do you have any difficulties that affect how you take your medication? E.g. problem swallowing, removing from container, inhalers etc
Is there any medication on your repeat list that you are no longer taking and can be removed?
Do you have any medication at home that you are no longer taking?
Do you have more than 4 weeks supply at home?
Is further action/help required with any of the above?

Blood Pressure

If you have a blood pressure monitor at home, please provide a couple of readings below or have them to hand when you speak to the clinician.



Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

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

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *


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Smoking status:
Please select all that apply:
Please select all that apply:

Weight, Diet and Physical Activity

Diet type:
Diet quality:

Additional Information

Family history (if known):
Ethnic group:

Please note, your ethnicity will make a difference on some testing results.

Additional Information