Medication side effect review questionnaire

1. I felt sleepy during the day *

N/A

Never

Once

A few times

Everyday

Thank you for submitting this questionnaire. A clinician will be in contact if they have any concerns.

I acknowledge - thank you

2. I felt drugged or like a zombie *

N/A

Never

Once

A few times

Everyday

3. I felt dizzy when I stood up and/or have fainted *

N/A

Never

Once

A few times

Everyday

4. I have felt my heart beating irregularly or unusually fast *

N/A

Never

Once

A few times

Everyday

5. My muscles have been tense or jerky *

N/A

Never

Once

A few times

Everyday

6. My hands or arms have been shaky *

N/A

Never

Once

A few times

Everyday

7. My legs have felt restless and/or I couldn't sit still *

N/A

Never

Once

A few times

Everyday

8. I have been drooling *

N/A

Never

Once

A few times

Everyday

9.3 My movements or walking have been slower than usual *

N/A

Never

Once

A few times

Everyday

10. I have had uncontrollable movements of my face or body *

N/A

Never

Once

A few times

Everyday

11. My vision has been blurry *

N/A

Never

Once

A few times

Everyday

12. My mouth has been dry *

NA

Never

Once

A few times

Everyday

13. I have had difficulty passing urine *

N/A

Never

Once

A few times

Everyday

14 (a). I have felt like I am going to be sick or have vomited *

N/A

Yes

No

14 (b). I have had problems opening my bowels (constipation) *

N/A

Yes

No

15. I have wet the bed *

N/A

Never

Once

A few times

Everyday

(16). I have been very thirsty and/or passing urine frequently *

N/A

Never

Once

A few times

Everyday

17. The areas around my nipples have been sore and swollen *

N/A

Never

Once

A few times

Everyday

18. I have noticed fluid coming from my nipples *

N/A

Never

Once

A few times

Everyday

19. I have had problems enjoying sex *

N/A

Never

Once

A few times

Everyday

20. Men only: I have had problems getting an erection *

N/A

Never

Once

A few times

Everyday

21. Women only: I have noticed a change in my periods in the last 3 months *

N/A

Yes

No

22. Men and women: I have been gaining weight in the last 3 months *

N/A

Yes

No

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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Medication side effect review questionnaire

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