Reception: Pill check + Asthma + Medication Review

Please note the form below will help you complete both a contraceptive, medication & asthma review.

You will need an up to date weight and blood pressure. Blood pressures can be done at home or in your local pharmacy.

Information on various contraceptive can be found below:

Regarding your asthma review, If your symptoms are significantly deteriorating or you are having any concerns please make a telephone appointment with our Nurse.

You may have received a text or a letter. This is because asthma reviews are an essential way of monitoring your symptoms and ensuring your medication is safe and appropriate.

Asthma Information Zone

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Pill check + Asthma + Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Medication Review

Do you have any concerns or side effects from your medication?This relates to all your medications if you are on more then just the oral contraceptive. Please state the medication and the side effect. E.g. Paracetamol: Constipation

Do you know when and how to take your medication?

Are you on any antidepressant medication?

If you are on antidepressants, can you please select the option which best applies to you?

What is your current blood pressure?e.g. 120/80 (Upper valve/Lower value). If you are unable to provide your blood pressure reading then you will need to attend an appointment at the surgery for a blood pressure check before your prescription can be issued.

What is your current height? (include units e.g. metres or feet)

What is your current weight?In Kg or Stones & lbs

Smoking History

If approved which pharmacy would you like us to send your prescription too?

If other please state pharmacy name & postcode

I confirm I have read through the links above which relate to my contraception option and understand what to do if I miss a dose or experience diarrhoea/vomiting

I understand that condoms are the only method of contraception that protects against Sexually Transmitted Infection; And that whilst it may not suit me at the moment I have considered a longer acting method of contraception (e.g. implant or coil)

Asthma Review

How often does your asthma cause symptoms during the day?

How often does your asthma cause symptoms at night?

How often does your asthma limit your activities?

On average, how many times a week do you need to use your reliever inhaler (Blue salbutamol/Ventolin inhaler)?

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

During the past 4 weeks, how often have you had shortness of breath?

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?

How would you rate your asthma control during the past 4 weeks?

How many asthma exacerbations have you had in the past 12 months?An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.

Is there anyone in your household who smokes?

Do you have any further information about your asthma that you feel is relevant to this review? Please note that your answer will not be seen immediately and you should direct any URGENT queries to reception.

Do you have an asthma care plan? If so when was it last reviewed?

I confirm I am happy to be contacted by the surgery on the mobile number provided if deemed necessary

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services

Physio

Aesthetic
& Wellness

Key Information

BBC Health News

Reception: Pill check + Asthma + Medication Review

Privacy Protection

Whitnash Medical Centre