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Mount Surgery NHS GP Surgery in Port Talbot

Medication review

Medication Review

Named GP (if known):

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

Yes

No

Which medications are you unsure as to why they have been prescribed? *

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

Yes

No

Please list the medications you are unsure how to take: *

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

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

Yes

No

For example, you are able to press the canister down on your inhaler or you can easily swallow the tablets.

Please describe the difficulties or barriers in taking your medication: *

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

Yes

No

Which of your medications are you taking differently to how they were prescribed? *

It is sometimes difficult to remember to take medication. Do you ever forget to take any of your medications? *

Yes

No

Please list the medications which you might sometimes forget to take: *

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

Yes

No

Please list these medications and any side effects you may be experiencing: *

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

Rather than a family member, friend, or carer managing your medications.

Please list any medications you feel you no longer need:

Smoking

Smoking status *

Smoker

Never smoked

Ex-smoker

How many per day do you smoke? *

When did you give up smoking? *

Alcohol consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How 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? *

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

Score:

Additional alcohol questions

How often during the last year have you found that you were not able to stop drinking once you had started? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking? *

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

No

Yes, but not in the last year

Yes, during the last year

Total score:

Height and weight

Height in metres: *

For example, 1.75

Weight in kilograms: *

For example, 60.6

Are you happy for the practice 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.

Margam Road
Margam
Port Talbot
SA13 2BN

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01639 502 792

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