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Medication Review Form

Last Updated: 11/08/2020

Personal Details

First name *

Surname *

Date of birth *

Smoking status

Enter your daily average. If you smoke a pipe, cigars or roll your own tobacco please choose 'Other'.

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes per day)

Heavy (20-39 cigarettes per day)

Very heavy (40+ cigarettes per day)

Other

Medication Review

Do you understand the purpose of your medications? *

Yes No

Do you take your medications as prescribed? *

Yes No

Do you experience any side effects? *

Yes No

If yes, what are they?

Do you have any questions or concerns about your medications? *

Further Information

Flu Clinics 2020
Viral Kindness
Carers Advice
GP Earnings
Practice Policies
Training in General Practice
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