Do you have any allergies

Do you smoke?

Do you know how and when to take your medications each day?

Do you take all of your medications as prescribed each day?

Do you understand why you are prescribed each of your regular medications?

Other than your medications supplied from us, do you take any other medication? This includes vitamins/ minerals/ herbal medication/ medications from any specialists:

Do you feel that your medication is working well for you?

Are you suffering any side effects from your medication?

Would you like to discuss any changes to your medication this year?

Depending on the answers provided on this form and your current medication/ diagnoses, the GP practice may authorise your medication for up to 12 months without requesting a medication review. However, if you experience any issues or have any concerns in the meantime, we would encourage you to seek a formal appointment to discuss this. Please tick “yes” if you are happy for the GP surgery to continue to supply your medication for up to the next 12 months without conducting a telephone or face-to-face medication review. If you have ticked “no” then please provide further information below.