Medication Review Name First Last Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Named GP (if known) OptionalDo you have any concerns or side effects from your medication? Yes No Please SpecifyDo you know when and how to take your medication? Yes No Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.HeightWeightSmokingSmoking status: 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 Would you like to give up smoking? Yes No Please visit NHS Stop Smoking> for more information about giving up smoking.Blood PressureAre you able to provide a blood pressure reading? Yes No Blood pressure readingSystolic / DiastolicDate of reading:Please use this date format: DD/MM/YYYY.Are you happy for the doctor to update your review date now? Yes No Consent I confirm that the information provided is accurate to the best of my knowledge
