Medication Review

We review any regular medication on a repeat prescription annually and wherever possible the doctor or clinical pharmacist 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.

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

Medication Review

Medication Review

Please check that the surgery has advised you to submit this form before doing so.


Is this your up to date telephone number? *


eg. 1.75
eg. 60.6
BMI calculator is only for patients aged 18 and over. The BMI will not calculate without a valid height and weight.

Blood Pressure

If you do not have access to a blood pressure machine, a reading can be done in the waiting room at the Healthy Living Centre or School Lane Surgery. Alternatively, some pharmacies have blood pressure machines available to the public for a small fee.

In Thetford, this is available at Lloyds Pharmacy, Sainsbury's, Forest Retail Park, London Road, IP24 3QL. For more information, please visit

To find another local Lloyds Pharmacy, please visit


Do you currently smoke? *

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Do you understand why you have been prescribed your medication and what it is for? *
Do you know when and how to take your medication? *

Please speak to a Pharmacist or a GP to discuss the above.

Do you remember to take your medication every day (if daily medication)? *
Do you have any concerns or side effects from the medication? *
Do you have any difficulties that affect how you take your medication? E.g. Problems swallowing, removing from containers, using inhalers or eye drops etc. *
Is there any medication on your repeat list that you are no longer taking and can be removed? *
Do you take medications for your mental health? *

Mental Health Medication

Are you happy with your current dose or treatment? *
Have there been any significant changes in your life since your mental health was last discussed? *
Do you have support from family, friends or other services? *
Do you take recreational drugs?
Do you drink alcohol?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *
Which of the following do you predominantly suffer with? *


Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *


Over the last 2 weeks, how often have you been bothered by any of the following problems:

Feeling nervous, anxious or on edge? *
Not being able to stop or control worrying? *
Worrying too much about different things? *
Trouble relaxing? *
Being so restless that it is hard to sit still? *
Becoming easily annoyed or irritable? *
Feeling afraid as if something awful might happen? *

Please select one of the following: *

Please list all of the medications that require a review:

Are you happy for your review date to now be updated? *