Medication Review

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 Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Medication Review

Please use this date format: DD/MM/YYYY.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

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

Smoking Review

Do not currently smoke section

Do currently smoke section

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:

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.
This is your total score the Alcohol Consumption form.

Blood Pressure

Please complete your most recent blood pressure reading below.
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