Anticoagulant Medication Review

If you have been advised by the surgery to submit an annual review of your anticoagulant (blood thinning) medication, please use this form. If you have any concerns please make an appointment with our Pharmacist.

Anticoagulant Medication Review

Anticoagulant Medication Review

Have you been asked by the practice to complete this online review? *
Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

e.g. 1.75
e.g. 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Smoking Status

Do you smoke?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Anticoagulant Review

Have you experienced any of the following in the past few months: prolonged bleeding, spontaneous bleeding (e.g. nosebleeds, blood in urine or stools), unusual bruising, exceptional weakness, tiredness, paleness or headache? *
Do you think you are experiencing any side effects from your anticoagulant medication?
Have you missed any doses of your anticoagulant in the past few weeks?
Not including your prescribed medication from the GP, do you take any other regular medication?
Do you carry an anticoagulant alert card with you at all times?
*