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Wilson Street Surgery Taddington Road Branch Surgery and St Thomas Road

Medication review

Medication Review

Section

Address:

Postcode:

NHS Number:

Named GP (if known):

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

Yes

No

Please specify:

Do you understand how to take each of your medications? *

Yes

No

Please specify:

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

Yes

No

Please specify:

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

Yes

No

Please specify:

Do you ever forget to take any of your medications? *

Yes

No

Please specify:

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

Yes

No

Please specify:

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

Do you manage your own medication? *

Yes

No

Please list any medications you feel you no longer need (A Doctor will need to agree before any changes are made):

What is your smoking status? *

Current Smoker

Ex-Smoker

Never Smoked

Please provide a home blood pressure reading, or you can use our Self-service blood pressure machine at any time:

Systolic (Higher):

Diastolic (Lower):

Heart Rate:

Height:

Weight:

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

Yes

No

Please specify:

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

Yes

No

Confirmation *

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

If you are human, leave this field blank.

Wilson Street Surgery
11 Wilson Street
Derby
DE1 1PG

Get directions

01332 332 628

Taddington Road Surgery
Taddington Road
Chaddesden
Derby
DE21 4JU

Get directions

01332 332 628

St Thomas Road Surgery
207 St Thomas Road
Derby
DE23 8RJ

Get directions

01332 332 628

Register with the surgery

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