Home Medicines Review Checklist
Please tick any that apply to you
Are you taking 5 or more medicines (including over the counter or herbal medicines)?
Do you know what each of your medicines is for?
Would you like more information about your medicines?
Do you feel your medicines are working properly?
Do you see other doctors apart from your regular GP?
Do you have any symptoms you feel are caused by your medicines?
Are you concerned about mixing up your medicines?
Would you like someone to help sort your medicine cabinet?
Have you recently been prescribed some new medicines e.g. in hospital?
Have you recently come out of hospital?
Do you sometimes forget to take your medicines?
Do you use anything to help you take your medicines, e.g. dosette, spacer?
Do you find it difficult to open the containers your medicines come in?
Do you eat regular meals?
Have you noticed a change in your weight recently?
Does food taste or smell differently?
Have you had any falls recently?
Would you like more information about generics - the cheaper options?
Would you like us to contact you to arrange an appointment with our doctors to begin the process?
Phone or Mobile Number
Is the Home services Review for yourself or for someone else?
Who are you acting on behalf of?
Your Spouse or partner
Your own child
A person you are the carer for
Name of person you are acting on behalf of
Should be Empty: