Medication Review Form Medication Review Name First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth DD slash MM slash YYYY Sex Male Female Prefer not to say Contact NumberEmail Are you happy for us to contact you by text messaging or email? Yes No Are you happy to receive test results by text messaging? Yes No Named GP (If Known) OptionalDo you have any concerns or side effects from your medication? Yes No Do you suffer with any side effects that you wish to discuss with your doctor/nurse? Yes No Do you feel your medical conditions are controlled? Yes No Do you take your medication regularly? Yes No Do you know when and how to take your medication? Yes No Are you happy to continue with your current medications? Yes No If you are on anti-depressant medication please can you also complete our Mental Health Review form which will give us useful information about how you are getting on and help us decide whether your medication dose needs to be reviewed. Clicking the link will open the form in a new tab, allowing you to submit this form before starting to complete the Mental Health Review.Are you taking any other medications that you buy over the counter from the pharmacist directly and that are not on your repeat prescription? Yes No Are you happy for the doctor to update your review date now? Yes No Do you currently smoke? Yes No Height & WeightHeight in CMWeight in KGSmoking ReviewDo you currently smoke? Yes No Have you smoked in the past? Yes No How many cigarettes did you smoke in a day? 0 1 – 9 10 – 19 20 – 39 40 or more How many cigarettes do you smoke in a day? 0 1 – 9 10 – 19 20 – 39 40 or more Would you like to give up smoking? Yes No Not Applicable Alcohol ConsumptionHow often do you have a drink containing alcohol? Never Monthly or Less 2-4 Times per month 2-3 Times per week 4+ Times per week How many units of alcohol do you drink on a typical day when you are drinking? I do not drink 1-2 3-4 5-6 7-9 10+ 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? Never Less than monthly Monthly Weekly Daily or almost daily Blood PressurePlease provide a blood pressure reading. This can be complete at home if you have a blood pressure monitor or you can come into the medical centres hub any time and use the blood pressure monitor.Heart RateSystolic "Higher"Diastolic "Lower"Confirmation I confirm that the information provided is accurate to the best of my knowledge.