{"id":1119,"date":"2026-08-22T10:58:02","date_gmt":"2026-08-22T09:58:02","guid":{"rendered":"https:\/\/surgeryweb-scot.org.uk\/n31916\/?page_id=1119"},"modified":"2026-08-22T10:58:02","modified_gmt":"2026-08-22T09:58:02","slug":"medication-review-form","status":"publish","type":"page","link":"https:\/\/surgeryweb-scot.org.uk\/n31916\/medication-review-form\/","title":{"rendered":"Medication Review Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_26' style='display:none'><div id='gf_26' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_26' id='gform_26'  action='\/n31916\/wp-json\/wp\/v2\/pages\/1119#gf_26' data-formid='26' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_26' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_26_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_1'><span class='gform-field-label__text'>Full Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_26_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_26_3' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_26_3_2_container'>\n                                        <label for='input_26_3_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_26_3_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_26_3_1_container'>\n                                    <label for='input_26_3_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_3[]' id='input_26_3_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_26_3_3_container'>\n                                        <label for='input_26_3_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_3[]' id='input_26_3_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_26_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-formatted gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_phone'>\n\t\t\t<div class=\"gform-phone\" role=\"application\">\n\t\t\t\t<div class=\"gform-phone__input-wrapper\">\n\t\t\t\t\t<span class=\"ginput_country-selector_container\">\n\t\t\t\t\t\t<label for='country_selector_button_4' id='country_selector_button_4_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n\t\t\t\t\t\t<button type=\"button\" id=\"country_selector_button_4\" class=\"gform-phone__country-selector gform-theme-button gform-theme-button--tertiary\" aria-haspopup=\"listbox\" aria-expanded=\"false\" aria-controls=\"gform_phone_dropdown_6a8a03a52fab6\" aria-label=\"Select country\" >\n\t\t\t\t\t\t\t<span class=\"gform-phone__flag-icon gform-phone__flag-icon--gb\"><\/span>\n\t\t\t\t\t\t\t<span class=\"gform-phone__dial-code\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<span class=\"ginput_phone_container\">\n\t\t\t\t\t\t<label for='input_26_4_visible' id='input_26_4_visible_label' class='gform-field-label gform-field-label--type-sub '>Phone Number<\/label>\n\t\t\t\t\t\t<input type=\"tel\" class=\"gform-phone__input\" id=\"input_26_4_visible\" name=\"\" autocomplete=\"tel\" value=\"\"   aria-required=\"true\" aria-invalid=\"false\"  >\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__dropdown gform-phone__dropdown--hidden\" role=\"listbox\" id=\"gform_phone_dropdown_6a8a03a52fab6\" tabindex=\"-1\">\n\t\t\t\t\t<div class=\"gform-phone__search-wrapper\">\n\t\t\t\t\t\t<input type=\"text\" class=\"gform-phone__search\" placeholder=\"Search countries\" aria-label=\"Search for a country\" aria-controls=\"gform_phone_dropdown_6a8a03a52fab6_list\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<ul class=\"gform-phone__country-list gform-ul-reset\" id=\"gform_phone_dropdown_6a8a03a52fab6_list\" role=\"listbox\" aria-label=\"Country list\">\n\t\t\t\t\t\t<!-- Country items will be populated by JavaScript -->\n\t\t\t\t\t<\/ul>\n\t\t\t\t\t<div class=\"gform-phone__aria-live-search-status\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; margin: -1px; border: 0; padding: 0; overflow: hidden; clip: rect(0, 0, 0, 0); clip-path: inset(50%); white-space: nowrap;\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__aria-live\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0 0 0 0); clip-path: inset(50%); border: 0; white-space: nowrap;\"><\/div>\n\t\t\t<\/div><input name='input_4' id='input_26_4' type='hidden' value='' class='large' data-phone-format='formatted' data-default-country='gb' data-show-country-code='false' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/fieldset><div id=\"field_26_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_5'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_26_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_26_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently taking all of the medication(s) on your repeat prescription list?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_30'>\n\t\t\t<div class='gchoice gchoice_26_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_26_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_30_0' id='label_26_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_26_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_30_1' id='label_26_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_46'><span class='gform-field-label__text'>Please give details of any medication(s) you have stopped taking and why<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_26_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you know when and how to take your medication?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_34'>\n\t\t\t<div class='gchoice gchoice_26_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_26_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_34_0' id='label_26_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_26_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_34_1' id='label_26_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you know what to do if you miss a dose of your medication?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_35'>\n\t\t\t<div class='gchoice gchoice_26_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_26_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_35_0' id='label_26_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_26_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_35_1' id='label_26_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you experience any side effects from your medication?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_36'>\n\t\t\t<div class='gchoice gchoice_26_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_26_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_36_0' id='label_26_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_26_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_36_1' id='label_26_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you feel your current medications are effectively treating\/managing your medical condition(s)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_37'>\n\t\t\t<div class='gchoice gchoice_26_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_26_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_37_0' id='label_26_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_26_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_37_1' id='label_26_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_47'><span class='gform-field-label__text'>Please provide more detail<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_26_47' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking any regular medications over the counter to help with your current medical condition(s) that are not on your repeat list?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_40'>\n\t\t\t<div class='gchoice gchoice_26_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_26_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_40_0' id='label_26_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_26_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_40_1' id='label_26_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_41'><span class='gform-field-label__text'>Please provide details below<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_26_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you wish to discuss any matters regarding your repeat prescription with the practice pharmacist\/GP?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_42'>\n\t\t\t<div class='gchoice gchoice_26_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_26_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_42_0' id='label_26_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_26_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_42_1' id='label_26_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you happy to continue with your current medications for the next 12 months and for us to update your prescription review date?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_9'>\n\t\t\t<div class='gchoice gchoice_26_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_26_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_9_0' id='label_26_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_26_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_9_1' id='label_26_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_20'><span class='gform-field-label__text'>Weight (kg)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_26_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_21'><span class='gform-field-label__text'>Height (cm)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_26_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_22'><span class='gform-field-label__text'>Blood pressure (mmHg) from a home monitor or via a local pharmacy that offers BP check<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_26_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Smoking Status<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_24'>\n\t\t\t<div class='gchoice gchoice_26_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Never smoked'  id='choice_26_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_24_0' id='label_26_24_0' class='gform-field-label gform-field-label--type-inline'>Never smoked<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Ex-smoker'  id='choice_26_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_24_1' id='label_26_24_1' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Current smoker'  id='choice_26_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_24_2' id='label_26_24_2' class='gform-field-label gform-field-label--type-inline'>Current smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date Stopped<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_26_25' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_26_25_2_container'>\n                                        <label for='input_26_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_25[]' id='input_26_25_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_26_25_1_container'>\n                                    <label for='input_26_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_25[]' id='input_26_25_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_26_25_3_container'>\n                                        <label for='input_26_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_25[]' id='input_26_25_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_26_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_26'><span class='gform-field-label__text'>Please advise how many cigarettes per day you smoke<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_26_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_26_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Alcohol intake - do you drink alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_26_27'>\n\t\t\t<div class='gchoice gchoice_26_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_26_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_27_0' id='label_26_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_26_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_27_1' id='label_26_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_26_28'><span class='gform-field-label__text'>How many units per week on average do you drink? 1 unit = half a pint of beer, a small glass of wine or one 25ml measure of spirit.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_26_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_29\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3>WHAT HAPPENS NEXT?<\/h3>\n<p>Once returned to the practice, a clinician will review your answers and issue your prescription as appropriate. <\/p>\n<p>If there are any queries or we have reason to speak with you before your prescription can be issued, you will be contacted to arrange an appointment. <\/p>\n<p>If there are no queries and we do not need to speak with you, your prescription will be issued for a year's supply* and sent to your preferred pharmacy. Please allow 7 working days before collection. <\/p>\n<p>We will ask you to complete this review yearly, prior to your prescription being reauthorised, to ensure that it remains appropriate for you to continue taking.<\/p><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_26' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> <input type='hidden' name='gform_ajax' value='form_id=26&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=2a1de305202ffa126e5fe224aeb36eea' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_26' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_26' id='gform_theme_26' value='gravity-theme' \/>\n            <input type='hidden' 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