Medication Review

 
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Personal Details
 
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Lifestyle
Smoking status: *

Alcohol consumption:

One unit:

  • Half a pint of regular beer, lager or cider
  • Half a small glass of wine
  • 1 single measure of spirits
  • 1 small glass of sherry
  • 1 single measure of aperitifs

More than one unit:

  • Pint of regular beer, lager or cider - 2 units
  • Pint of strong or premium beeer, lager or cider - 3 units
  • Alcopop or a 275ml bottle of regular lager - 1.5 units
  • 440ml can of regular lager or cider - 2 units
  • 440ml can of super-strength lager - 4 units
  • 250ml glass of wine (12%) - 3 units
  • 75cl bottle of wine (12%) - 9 units
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Medication
Do you take any medication?: *
How long do you think you will be taking your medication?: *
Please choose from one of the following: *
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Confirmation

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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