Dispensing Review of Use of Medication Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Who are you completing this form for?YourselfSomeone elseFor example, on behalf of a child or dependent.What is the patient's name? *FirstLastWhat is the patient's date of birth? *What is the patient's sex? *MaleFemaleOtherAs recorded on their medical recordWhat is the patient's postcode? *The one used to register with their GP.What is your relationship to the patient?ParentGuardianSpouseCarerSonDaughterSiblingOtherWhat is your name? *FirstLastWhat is your date of birth? *What is your sex? *MaleFemaleOtherAs recorded on your medical record.What is your postcode? *The one used to register with your GP.What is your phone number?What is your email address? *Anyone else with access to your email account may see responses sent to you.Concordance: Do you understand the purpose of each of your medications? *I understand why I am taking each of my medicationsI do not understand why I am taking each of my medicationsConcordance: Please provide further details, if possibleCompliance: Do you take your medication as directed on the labels? *I always take medication as directed on the labelsI mostly take medication as directed on the labelsI never take medication as directed on the labelsEfficacy: Are your medicines effective in controlling your symptoms? *My medication always controls my symptomsMy medication controls my symptoms most of the timeMy medication never controls my symptomsSide Effects: Do you suffer from any side effects from any of your medication? *YesNo your prevent directed Side Effects: Name of medication *Side Effects: Nature of side effect *Do any of the following prevent you from being able to take your medication? Problem swallowingSide effectsDifficulty opening containersReduce Wastage: Have you stopped taking any medication that can be removed from your repeat list? *YesNoReduce Wastage: Name of medication *Do you use your medications in date order, using the previous issue up before you start on the new issue? *YesNoSubmit