Hypertension Medication Review Form
Please complete this form to help us review your current blood pressure medication and overall health.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List all current blood pressure medications (include dosage and frequency)
*
Most recent blood pressure reading (mmHg)
*
Have you experienced any symptoms or side effects from your medications?
*
Dizziness
Swelling
Cough
Fatigue
None
Other
How often do you miss taking your blood pressure medication?
*
Never
Rarely
Sometimes
Often
Do you have any known drug allergies?
*
No
Yes (please specify below)
Relevant medical history (e.g., diabetes, kidney disease, heart problems)
Lifestyle factors (select all that apply)
Smoker
Alcohol use
Regular exercise
Special diet
None
Submit Review
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