Medicines Use Review Questionnaire


About Your Medication

Have there been any changes with your medicines in the last one year? *
Are you taking your medication as prescribed? *
Do you know what your medicines are for? *
Do you think your medication(s) is/are working? *
Do you suffer any side-effects from medication? *
Do you order all your medication at the same time? *
Are you on any Over-The-Counter medicines (including herbal medicines)? *

Lifestyle Questions

Do you smoke? *
Do you do regular exercise? *
Do you drink any alcohol? *


I agree that the information obtained during the service can be shared with:

• My doctor (GP) to help them provide care to me
• NHS England (the national NHS body that manages pharmacy and other health services) to allow them make sure the service is being provided properly by the pharmacy
• NHS England, the NHS Business Services Authority (NHSBSA) and the Secretary of State for Health to make sure the pharmacy is being correctly paid by the NHS for the service they give me.