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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.

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Reception: Pill check + COPD + Medication review

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.

This could be inbetween your periods if you have a regular cycle, or after sex
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.
In Kg or Stones & lbs
Please tick the box against any conditions YOU have been diagnosed with.
Please tick the box next to any conditions that are present in your family:
Medication Review
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
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.
Declaration
Chronic Obstructive Pulmonary Disease (COPD) review
Do you have a cough and if so when in the day is it worse?
Ignore question if your cough is dry
MRC score: Select the option below which most applied to you.

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Whitnash Medical Centre

110 Coppice Road , Whitnash, Warwickshire, CV31 2LT

  • 01926 316711
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Local Services
Aesthetic
& Wellness
Physio