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Medication review

Medication Review

Section

Do you have any concerns or side effects from your medication?
Do you know when and how to take your medication?

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?

Blood Pressure

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Alcohol Consumption

This is one unit of alcohol:

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

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?

As you’ve scored more than 5 this may indicate increasing or higher risk of drinking. Please complete the second section of the questionnaire.

Alcohol Consumption – Part 2

How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Confirmation

Phoenix Cirencester
9 Chesterton Lane
Cirencester
GL7 1XG

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01285 652056

Phoenix South Cerney
Clarks Hay
South Cerney
Cirencester
GL7 5UA

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Phoenix Royal Agricultural University
Cirencester
Gloucestershire
GL7 6JS

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Phoenix Kemble
Church Road
Kemble
Cirencester
GL7 6AE

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41-43 Long Street
Tetbury
Gloucestershire
GL8 8AA

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