Medication Review Your First Name(s): Last First Name(s) as appears on your passport.Your Last Name: Last Last Name(s) as appears on your passport.Postcode: Postcode The one used to register with your GP.Your Date of Birth: Day Month Year Your date of birth is required to verify your identity.Sex: Male Female Other As on your medical recordYour Phone Number:The practice may use this number to contact you about your request.Your Email: Enter Email Confirm Email This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.Named GP (if known): Optional Does this review concern all of your medication? Yes No Are there any concerns or side effects from the medication? Yes No Do you know when and how to take your medication? Yes No Please specify how you take your medication.Do you smoke? Yes Optional No Optional What is your current weight? Optional 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 blood pressure reading: (optional)Systolic "Higher" Optional Diastolic "Lower" Optional Heart Rate Optional Do you take medication for your mental health? Yes No Alcohol Units2 units = 1 pint beer or 1 glass of wine (175mls), 1 unit = single measure of spirits, 1.5 units = alcopop or a can of Lager, 9 units = 1 bottle of wine.How often do you have a drink containing alcohol?NeverMonthly or less2-4 times per month2-3 times per week4+ times per weekHow many units of alcohol do you drink on a typical day when you are drinking?1-23-45-67-910+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?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyNext StepsIf you need your medication issued now, please request it in the usual way. I confirm that the information provided is accurate to the best of my knowledge