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Home > Reception: Pill check + COPD + Medication review

Reception: Pill check + COPD + Medication review

This form will help us review your COPD, contraceptive pill & any other medications.

You will need an up to date weight and blood pressure.

Information on various contraceptive options can be found below:

Combined pill

Progesterone only pill

Contraceptive patch

Vaginal ring

This form also will ask you a number of questions about your COPD. It is important that this is done at least yearly to ensure we are keeping track of your symptoms.

COPD Information Page

Calculate your CAT Score (compulsory)

Inhaler Technique

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 + COPD + Medication review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

What form of contraception are you currently using?

Would you like to continue with your current method?

If no, why not? And which alternative would you like to use?

Some medical conditions can mean hormonal contraception is not a safe option. Please answer the following questions below about your own health and family history.

Are you experiencing any irregular or unusual bleeding?This could be inbetween your periods if you have a regular cycle, or after sex

Have you noticed any new headaches since starting your current method of contraception?

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

Have you given birth within the last 6 weeks

Are you currently breastfeeding?

Please tick the box against any conditions YOU have been diagnosed with.

None

Heart disease, high blood pressure or stroke

Blood clots

Breast cancer

Carrier of gene mutation associated with breast cancer e.g. BRCA 1 or 2

Migraine

Liver Problems

Diabetes

Pregnancy complications (e.g. high blood pressure or cholestasis)

Current unexplained vaginal bleeding or bleeding after sex

High cholesterol

Previous abnormal cervical smear

HIV/AIDS

Gallbladder disease

Thrombophlebitis (inflammation of varicose veins)

Inflammatory bowel disease

Sickle cell disease

Raynaud’s disease

Rheumatoid arthritis/lupus

Atrial fibrillation

Immobility

Please tick the box next to any conditions that are present in your family:

None

Heart disease, high blood pressure or stroke

Blood clots

Breast cancer

Carrier of gene mutation associated with breast cancer e.g. BRCA 1 or 2

If you have ticked against a condition above, please provide details of age at time of diagnosis and relationship to you

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 struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

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

If other please state pharmacy name & postcode

Declaration

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)

Chronic Obstructive Pulmonary Disease (COPD) review

How often do you suffer with a cough?

Do you have a cough and if so when in the day is it worse?

No cough

Dry cough

Productive cough (brings up phelgm)

Morning

Daytime

Evening

Constant

If you are bringing up phlegm what colour is it?Ignore question if your cough is dry

MRC score: Select the option below which most applied to you.

1 – Not troubled by breathless except on strenuous exercise

2 – Short of breath when hurrying on a level or when walking up a slight hill

3 – Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

4 – Stops for breath after walking 100 yards, or after a few minutes on level ground

5 – Too breathless to leave the house, or breathless when dressing/undressing

Please calculate your CAT score using the link at the top of the form. Once calculated please document it here

Are you happy with your inhaler technique?

Do you use a spacer?

How many occasions have you had to use antibiotics this year for your COPD?

How many times have you been admitted to hospital due to your COPD this year?

I confirm that the information provided is accurate to the best of my knowledge

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This information is retained for up to 28 days.

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