FORGETTING TO TAKE MEDICINE?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Do you sometimes forget to take your medication?
Yes No
If yes, would you like to be reminded to take your medication?
Yes No
Do you take medication at different times in the day?
Yes No
Do you need help organising your medication?
Yes No
Do you find opening bottles or blister packs difficult?
Yes No
Do you need help using ear or eye drops?
Yes No
Do you misplace your medication?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No