Mental Health Medication Review

At The Glen Medical Practice we want to ensure we are reviewing your prescriptions regularly to ensure you are prescribed an appropriate dose of your medications. It would be helpful if you could fill in this questionnaire to help us understand your current symptoms to guide your treatment. If you feel you need to discuss your medication in more detail, please do not hesitate to make an appointment with the GP or Practice Pharmacist.

The purpose of this questionnaire is to monitor medication once your mental health condition is stable.

If you experience any acute worsening of your condition such as having thoughts about harming yourself, concerns regarding drugs or alcohol or deterioration in symptoms of depression or anxiety please contact us urgently for an appointment.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Named GP (if known)

Mental Health Medication Review

Are you taking your medication as prescribed? *

Yes No

Do your feel your prescription is helping your mental health at the current dose? *

Yes No

Are you experiencing any side effects which you think may be related to your medication? (If "yes" please make an appointment to discuss this with our Practice Pharmacist) *

Yes No

Do you smoke? *

How much alcohol do you drink on average per week (1 pint = 2 units, 1 medium glass of wine = 1 unit, 1 spirit measure = 1 unit) *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 19 September 2025
Page created: 19 September 2025

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