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Medication review

Please use this date format: DD/MM/YYYY.

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

If blood pressure is not known and you don’t have a machine at home please check your blood pressure on the POD at reception.
Please specify either Kg or stone or not known.

Smoking Review

Do not currently smoke section

Do currently smoke section

Please ask at reception for more information about giving up smoking.

Alcohol Consumption

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

This is your total score from the first part of the Alcohol Consumption form.

Alcohol Consumption – Part 2

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.
This is your total score the Alcohol Consumption form.