Cumberland House Medication Review Questionnaire

Please only complete this questionnaire if you have received a request from us to do so. Thank you.

Please complete as many of the questions below as you can. Questions marked with a star must be completed. Once completed, please click on the “Submit” button at the bottom of the form to send your answers to us.

Your medications should be reviewed annually to ensure that you are taking the appropriate medications at the appropriate dose and to give you an opportunity to raise any concerns you may have. Current restrictions unfortunately mean that we cannot see all our patients in person so we have developed this form to use as the basis of our medication reviews. Please complete this as fully as possible. Your answers will be reviewed and you may be contacted by our clinical pharmacist if necessary. If you do not hear from us this means we have been able to sign off your medication review from the responses you have given.

Thank you for your understanding in these strange times.

Please refer to your repeat prescription list on your most recent prescription when answering the following questions.

1. Contact Details

_________________________________________________________________________________________

2. Medication Details
Are you currently taking all the medications on your repeat prescription list?
YesNo

If you have answered no, please give details of any medication(s) you have stopped taking in question 3.
If you have answered yes, please move on to question 4.

_________________________________________________________________________________________

3. Medication you are no longer taking
Medication 1 Name:

Reason for stopping medication:

Problem you were taking it for has resolvedSide effectsDifficult to take / usePersonal PreferenceOther (please give reason below)
Medication 2 Name:

Reason for stopping medication:

Problem you were taking it for has resolvedSide effectsDifficult to take / usePersonal PreferenceOther (please give reason below)

If you have stopped taking more than two items, please give further details below:

_________________________________________________________________________________________

4. Regarding the medications you are still taking
Do you have any concerns about any of your medication?
YesNo
Do you have too much medication because you have been supplied with more than you need?
YesNo
Do you understand why you are taking each medication?
YesNo
How often do you take your medications as instructed on the label?
AlwaysOftenSometimesRarelyNever
What do you usually do if you forget to take a dose of your medication?
Would you be willing to buy any of your medications if they are available over the counter?
YesNo
(Asking this is a national policy to help save NHS money so that it can be spent on other medicines and services)

_________________________________________________________________________________________

5. Other Medications
Do you take any regular medications that are not prescribed by a doctor?
YesNo
Do you use any herbal or homeopathic remedies?
YesNo

_________________________________________________________________________________________

6. Additional Information
Please use this space for anything else you wish to share with us about your medication.

Thank you for completing the medication review form.

For an appointment or clinical advice, contact your practice