Medication review

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Named GP (if known):

Do you have any concerns or side effects from your medication?

Yes

No

Please specify:

Are you taking medication to control your blood pressure?

Yes

No

Blood Pressure

Please provide us with the last 3 blood pressure readings you have taken at home.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Day 1

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 2

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Day 3

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Do you know when and how to take your medication?

Yes

No

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

Are you happy for the doctor to update your review date now?

Yes

No

I confirm that the information provided is accurate to the best of my knowledge

Required

I confirm that I am a patient at Grovelands Medical Centre, London.

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Blood Pressure