Medication review

Section

Named GP (if known):

Do you understand the reason why you are taking each of your medications?

Yes

No

Which medications are you unsure as to why they have been prescribed?

Do you understand how to take each of your medications?

Yes

No

Please list the medications you are unsure how to take:

Do you find it easy to take each of your medications?

Yes

No

For example, you are able to press the canister down on your inhaler or you can easily swallow the tablets.

Please describe the difficulties or barriers in taking your medication:

Are you currently taking each of your medications as they are prescribed on the label?

Yes

No

Sometimes

Which of your medications are you taking differently to how they were prescribed?

It is sometimes difficult to remember to take medication. At times do you forget to take any of your medications?

Yes

No

Sometimes

Please list the medications which you might sometimes forget to take:

Do you get any side effects from the medication you are taking?

Yes

No

Please list these medications and any side effects you may be experiencing from them:

If you take any other medications (including supplements or herbal remedies) that have not been prescribed, please list them here:

Please list any medications you feel you no longer need:

Do you manage your own medication?

Yes

No

Rather than, for example, a family member, friend or carer managing your medications?

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

Yes

No

Smoking Review

What is your smoking status?

Current Smoker

Ex-smoker

Never Smoked

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

How many cigarettes did 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.

Are you able to provide a blood pressure reading?

Yes

No

As part of a medication review, it is useful to have an up-to-date blood pressure reading.

Blood Pressure

Before you take your blood pressure reading:

Sit down comfortably for 5 minutes.
Wear loose-fitting clothing.
Make sure your arm is around the same level as your heart.
Make sure your arm is relaxed.

When taking your blood pressure:

Put the cuff on following the instructions that came with your blood pressure monitor.
Keep still and silent.

Other tips:

Take at least three readings, each two minutes apart.
Your first reading may be much higher than the next readings. If this is the case, keep taking readings until they level out and stop falling. Use this as your reading.

Please seek urgent medical attention if you develop any of the following:

Blood pressure is 170/115 or above (despite repeating it at least 2 times).
Chest pain.
Changes in vision.
Confusion.
Severe headache.

For more tips or to learn more, visit the British Heart Foundation website.

Please enter your Systolic (SYS) blood pressure reading (the higher number):

Please enter your Diastolic (DIA) blood pressure reading (the lower number):

Height and Weight

Are you able to provide a weight and height reading?

Yes, both

Weight Only

Height Only

No

Weight (in Kilograms):

eg. 60.6

Height (in Metres):

eg. 1.75

Do you have any other concerns relating to any of your medications?

Confirmation

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

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