Patients prescribed Pregabalin and Gabapentin – information regarding changes to your prescription

Update Your Details

Name*
First Last
Date of Birth*
Address*
Telephone (home)
Telephone (mobile)
Email
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Privacy*
- By using this form you agree with the storage and handling of your data by this website.

Name*
Please give us your full name
Date of Birth*
First line of your home address*
e.g. 45 Cherry Tree Road
Do you currently smoke?*
In the last month, have you had difficulty sleeping due to your asthma symptoms?*
(including cough)
In the last month, have you been troubled by your asthma symptoms during the day?*
(cough, wheeze, chest tightness or breathlessness)
In the last month, has your asthma interfered with your usual activities?*
(housework, work, school etc)
Thank you for completing this review

If you have answered YES to any of the above questions, it is very important that you make an appointment to have a face-to-face review with a practice nurse. We may need to change your medication. If you have answered NO to all three questions, we will complete your asthma review for the year, however in certain circumstances we may contact you by phone to discuss your medication and whether it should be changed or stopped. Please note the details you have provided will be used to update your records, and should your symptoms worsen at any time you should contact us.

Name*
Date of Birth*
First Line of Address*
e.g 40 Cherry Tree Lane
I consent to the sharing of my medical records with other health professionals involved in my care.*
- I consent to share all of my health information
- I consent to share only my basic information (my medications and allergies)
- I do not consent to share any of my information
I understand if I consent to share all of my health information - this includes my current health conditions, my current medications, any allergies I may have, any recorded information regarding my family relationships (i.e. my next of kin) and information about my decisions regarding my preferred place of care.