Patient Medication Review Questionnaire

Dear patient

Thank you for taking the time to complete the online medication review form. We are currently trialling this way of working to see if we can help to create more capacity for patient appointments with the GP. The GP will review all completed medication review forms. However, please be aware that you may still be required to attend an appointment for a medication review if the GP thinks that this is necessary.

Please do not use this form for any other medical queries either routine or urgent.

The form includes information on alcohol consumption. The following link is a useful guide on calculating on many units of alcohol you may consume.

Alcohol units - NHS (www.nhs.uk)

Complete all questions on this form

Medication Review

Are you completing this form on behalf of:

Yourself

Someone else (e.g. child or dependent)

What is your relationship to the patient?

About you (The patient)

Your first name

Your surname

Date of Birth

Your address

Your post code

Sex

Your landline telephone numberInsert if applicable

Your mobile telephone number

Your email addressThis email address may be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see the response you sent.

Are you happy for us to contact you by SMS text message or email?

Are you currently taking all the medications on your repeat prescription list?

If you have answered no, please give details of any medication(s) you have stopped taking?

Please indicate the reason(s) why you have stopped taking the medication(s) you have listed above?

Please give reason below

Do you know when and how to take your medication?

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

If yes please give further information below

Do you feel you medical conditions are controlled/stable?

Are you happy to continue with your current medications?

Are you taking any medications that you buy over the counter from the Pharmacist directly and that are not on your repeat prescription?

If you have answered yes, please list the names of any medications that you have purchased directly from the pharmacy

Do you wish to discuss any matters regarding your medications with the Practice Pharmacist/GP?

Are you happy for the GP/Practice Pharmacist to update your review date now?

Height Weight

Please provide your height and weight for our records if known?

Height in centimetres or feet and inches

Your current weight in kilograms or stones & pounds

Smoking review

Do you currently smoke?

Have you smoked in the past?

How many cigarettes do you smoke in a day?

Alcohol consumption

How often do you have a drink containing alcohol?

How many units of alcohol do you drink in a typical day when drinking? (See guide above for information)

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?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Park Medical • Great James Street Health Centre, Great James Street, Derry, BT48 7DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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