Repeat Medication Screening Tool

Dear Patient,

Please only complete this form when you are prompted by the practice to do so.

This form will help us identify if you are having any difficulties with your medication.

There are no right or wrong answers, we would like your honest feedback.

This should take no longer than 5 minutes to complete.

Last Updated: 25/04/2024

  • PATIENT DETAILS

    Date of Birth
    For example, 15 3 1984

  • LIFESTYLE

    Smoking Status
    If current or ex-smoker, how much do/did you smoke a day (optional)

  • MEDICATION

    Do you take all the medication on your repeat slip?
    Are you taking the medication as directed on the labels?
    Do you know why you are taking each medication prescribed?

  • SIDE EFFECTS AND ADMINISTRATION

    Do you feel that your medication is causing any side effects?
    Are you having any difficulties administering or taking your medication?

  • ORDERING AND STOCK

    Are you having any issues ordering or collecting your medication?
    Do you have an excess of any medication at home?
    Are there any items on you repeat form you no longer need?

  • OVER THE COUNTER MEDICATION?

  • ADVICE

    SMOKING: If you smoke, please see www.helpmequit.wales stop smoking advice and support

    ALCOHOL: If you are consuming over 14 units per week, please see www.drinkaware.co.uk for alcohol consumption advice

    BMI: Please calculate your BMI at 111.wales.nhs.uk/LiveWell/BMIcalculator/

    If your BMI is under 18.5 and over 24.9, please see 111.wales.nhs.uk/livewell for lifestyle advice

     

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