Prescriptions: Medication Review

We review any regular medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form. Ensure that you complete any outstanding blood test requests prior to filling out this form. You will know if you need to have a blood test by reading the prescription note or text message you were sent by us.

Certain medications need regularly monitoring (often yearly). This may include

Bloods Tests
Blood pressure checks

You will be contacted by our team if this is required.

Antidepressant review mood questionnaire calculator (PHQ9)

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 7 working days to complete. Please DO NOT call before 7 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Prescriptions: Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

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

If yes - Please explain what side effects or issues you have experienced

Do you know when and how to take your medication?

Please record your most recent home/hospital/pharmacy blood pressure:

Are you on any antidepressant medication?

Please state what score you calculated on the mood questionnaire PHQ-9 (LINK ABOVE). Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.

If you are on antidepressants, can you please select the option which best applies to you?If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

Are you happy to continue taking the medication at the current dose and in the current form ?

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

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

What is your current smoking status?

How many units of alcohol do you consume per week?

What is your current weight? (In Kg or Stones)

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

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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