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Annual medication review

Annual Medication Review

Section

If you are completing this form on behalf of someone else, please enter their details in the following sections.

Are there any concerns or side effects from the medication?
Are these effects manageable?
Do you know when and how to take your medication?
Do you take your medication as prescribed?
For example, follow the instructions on the box.
Do you ever forget to take your medication?
For example, how often this happens, which medicines, and any reasons why.

Smoking Questions

Do you smoke? *

Stopping smoking is one of the best things we can do to improve our health and it’s never too late to quit.

Would you like help to quit smoking? *

However long you have smoked and whatever your circumstances, Smokefree Norfolk can provide support.

Please go to Smokefree Norfolk (opens in new tab) or call 0800 0854 113 to refer yourself directly.

Do you use an e-cigarette or vape?
Would you like help to quit vaping or using e-cigarettes?

Please see the following websites with resources on how to quit or reduce vape use:

Only answer this question if you have weighed yourself. Please do not guess.

If you have a home blood pressure monitor, please can you provide a recent blood pressure reading (optional):

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Do you take medication for your mental health? *

Further Questions

Have there been any significant changes since we last discussed your mental health? *
Do you think your mental health is getting better, getting worse, or staying the same? *

For immediate help

This is not an emergency form. If you are experiencing thoughts of harming yourself or feel you may be in crisis, please do not use this form for urgent help.

Contact the surgery directly, or call 111 and select option 2 for urgent mental health support.

Additional Questions

Do you take any recreational drugs? *

Alcohol consumption questions

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 alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Additional alcohol consumption questions

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Next Steps

What would you like the practice to do now? *

The practice will contact you if we need to discuss your medication.

How would you prefer us to contact you? *

If you need your medication issued now, please request it in the usual way.