Medication Review v2

If you have been asked to complete an online medication review, or have been unable to re-order your medicines online, please use the form below. This will be processed by our medications team and passed to the pharmacist if needed. Please only use this form for medication, and not for other clinical queries.

Last Updated: 13/01/2021

Patient Details

Patient's Full Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Name and relation of person completing form (if different from above) (optional)

Which pharmacy do you use?
Medication List

Please list all medications (including those bought over the counter) that you take, and the dosages if possible
General Review Questions

Do you know why you take each of your medications? (optional)

Yes

No

How often do you forget or miss doses? (optional)

Who manages your medication for you? (optional)

Are you experiencing any side effects? If so, please explain below (optional)
Blood pressure

If you take any medications for your blood pressure, please provide at least 3 readings, ideally taken on different days. (optional)
Patient Questions

If you have any queries or questions about your medication to ask our pharmacist, please include them below. (optional)

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Medication Review v2

Patient Details

Medication List

General Review Questions

Blood pressure

Patient Questions