Medication Review Form
A structured review of everything a patient takes, how well they are managing it, the side effects they notice, and what they would like changed.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 16 questions, 2 pages, 3 conditional rules.
- Questions
- 16
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 6 min
- Conditional rules
- 3
Searches this template answers
- medication review form
- medicines review form template
- medication reconciliation form
- pharmacy medication review form
- patient medication list form
- annual medication review form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 2 — What you take
Every question on this page is currently visible.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Medication Review Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 16 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 8 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Medication Review Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “Do you ever miss doses?” is Yes, sometimes, “What usually gets in the way?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Have you noticed effects you think are from a medicine?” is Yes, “Which medicine, and what happens?” becomes mandatory before the form can be sent.
- Features advanced show logic: if “Is cost an obstacle?” is Yes, the form dynamically exposes “Which items are hardest to afford?”. Otherwise that question never appears.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
A medication review works only if the patient's real list is on the table, including the things they buy themselves and the doses they have quietly adjusted. This form asks for that list before the appointment, in two parts. The first records everything taken: prescribed medicines with strength and frequency, anything bought over the counter, supplements, and anything stopped since the last review. The second is about how it is going in practice — missed doses and why, whether the routine is manageable, whether anything is hard to swallow, open or afford, and whether the patient has noticed effects they attribute to a medicine. Those questions matter more than a printed list, because they surface the reasons a regimen is not being followed rather than assuming it is. A final question asks what the patient would most like to change, which frequently reframes the review. The form gathers information only. Every decision about starting, stopping or adjusting a medicine remains with the prescriber reading it.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — What you take
- Patient full namerequired
- Date of birthrequired
- Prescribed medicines, strength and how oftenrequired
- Anything bought without a prescription
- Vitamins, supplements or herbal products
- Anything stopped since the last review
- Usual pharmacy
Page 2 — How it is going
- Do you ever miss doses?required
- What usually gets in the way?
- Is the routine manageable?required
- Any practical problems?required
- Have you noticed effects you think are from a medicine?required
- Which medicine, and what happens?
- Is cost an obstacle?required
- Which items are hardest to afford?
- What would you most like to change?
16 questions in total.
Example of a completed medication review form
A sample review showing how a patient reports their current medicines and how they are managing them.
- Patient full name
- Robert Kowalski
- Date of birth
- 08/05/1958
- Prescribed medicines, strength and how often
- Atorvastatin 20mg nightly; Amlodipine 5mg each morning
- Anything bought without a prescription
- Occasional paracetamol for joint pain
- Do you ever miss doses?
- Yes, sometimes
- What usually gets in the way?
- Forgetting the evening dose when travelling
- Is the routine manageable?
- Mostly
- Have you noticed effects you think are from a medicine?
- No
- What would you most like to change?
- Fewer times a day if possible
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Do you ever miss doses?”
- Makes answers required
If “Do you ever miss doses?” is Yes, sometimes, “What usually gets in the way?” becomes required before the form can be submitted.
Driven by “Have you noticed effects you think are from a medicine?”
- Makes answers required
If “Have you noticed effects you think are from a medicine?” is Yes, “Which medicine, and what happens?” becomes required before the form can be submitted.
Driven by “Is cost an obstacle?”
- Reveals questions
If “Is cost an obstacle?” is Yes, the form reveals “Which items are hardest to afford?”.
Set it up step by step
- 1
Send it a week ahead
Patients need time to collect packets and read labels; answers written at the kitchen table are far more accurate than ones recalled in the room.
- 2
Ask patients to copy labels
Strength and frequency copied from the box beats a remembered colour or brand every time, and it makes reconciliation possible.
- 3
Treat the practical questions as clinical
Packaging, swallowing and cost answers explain more non-adherence than any question about willingness does.
- 4
Bring the answers into the consultation
Open the submission during the review so the conversation starts from the patient's own list rather than the repeat screen.
Mistakes to avoid
- Reviewing only the prescribed list and missing what the patient buys themselves.
- Asking whether doses are missed without asking why, which loses the only actionable part.
- Using the form to record decisions, when it is designed to gather what the patient reports beforehand.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Reconcile the reported list against the record before the appointment, discuss the practical obstacles first, and document any agreed change in the prescribing record afterwards.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the medication review form, matched on the words people actually search for.
Care Plan Review Form
annualcarechangedclinicclinical
Patient History Form
clinicclinicalclinicianhealthhistory
Quick Refill Request
clinicclinicalhealthhistoryintake
Discharge Follow-Up Form
careclinicclinicalcoordinatorhealth
Fall Risk Assessment Form
clinicclinicalhealthhistoryintake
Dental Treatment Plan Consent Form
clinicclinicalcoordinatorhealthhistory
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Can pharmacists use this without the practice?
Yes. The questions are written from the patient's perspective, so a community pharmacy review works the same way, and the submission can be shared with the prescriber afterwards.
How does it relate to the Quick Refill Request?
The refill request is a routine ask for more of the same. This form is the periodic look at whether the regimen still fits, and it is much longer for that reason.
Should the form suggest changes?
No. It records what the patient reports and wants to discuss; every decision about a medicine sits with the prescriber reading the answers.
What about patients with long lists?
The free-text lines take as many entries as needed, and asking for one medicine per line keeps a fifteen-item list readable during the review.
Is the Medication Review Form template free to use?
Yes. You can preview and test Medication Review Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Medication Review Form template ask for?
It asks 16 questions across 2 pages, 8 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Medication Review Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Do you ever miss doses?” is Yes, sometimes, “What usually gets in the way?” becomes mandatory before the form can be sent. Features conditional validation: if “Have you noticed effects you think are from a medicine?” is Yes, “Which medicine, and what happens?” becomes mandatory before the form can be sent. Features advanced show logic: if “Is cost an obstacle?” is Yes, the form dynamically exposes “Which items are hardest to afford?”. Otherwise that question never appears. All rules are editable in the Logic tab.
Where do responses to the Medication Review Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Medication Review Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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