Medication Review Questionnaire

At Kenilworth Medical Practice we want to ensure we are reviewing your prescriptions regularly to ensure you are prescriptions regularly to ensure you are prescribed an appropriate dose of your medications. It would be helpful if you could fill in this questionnaire to help us understand your current symptoms to guide your treatment. If you feel you need to discuss your medication in more detail, please do not hesitate to make an appointment with the GP or pharmacist.

The purpose of this questionnaire is to monitor medication once your mental health condition is stable. If you experience any acute worsening of your condition such as having thoughts about harming yourself, concerns regarding drugs or alcohol or deterioration in symptoms of depression or anxiety please contact us for an appointment.

Last Updated: 11/01/2024

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Medication Required

Are you taking your antidepressant medication as prescribed *

Yes

DO YOU FEEL YOUR PRESCRIPTION IS HELPING YOUR MENTAL HEALTH AT THE CURRENT DOSE *

YES

ARE YOU EXPERIENCING ANY SIDE EFFECTS WHICH YOU THINK MIGHT BE RELATED TO YOUR MEDICATION (If answered yes and you would like to discuss alternative medication please make an appointment to discuss this with the GP or our pharmacist *

YES

DO YOU CURRENTLY SMOKE *

YES

HOW MUCH ALCOHOL DO YOU DRINK PER WEEK ON AVERAGE? 1 Pint = 2 units 1 Medium class of wine = 1 unit 1 measure spirit = 1 unit AGE *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Kenilworth Medical Centre website

Medication Review Questionnaire

Further Information