PATIENT MEDICATION HISTORY INTERVIEW FORM

Pharmacist’s name: Date & Time:

PATIENT’S DEMOGRAPHIC & BACKGROUND DETAILS:

Name: Age / Sex: Location:

Gender: Male Female Marital status: Single Married Occupation:

Diet: Exercise: Alcohol:

Smoking: Recreational drugs:

MEDICAL HISTORY:

Diabetes Hypertension Heart Disease Respiratory Problems Other Medical Problems

ALLERGIES:

Medication allergies:

Food / Chemical allergies:

VACCINATION DETAILS:

DEPARTMENT OF PHARMACY PRACTICE, MLR INSTITUTE OF PHARMACY

 PATIENT MEDICATION HISTORY INTERVIEW FORM
PRESCRIPTION MEDICATIONS (should ask for all type of medications including eye / ear drops, patches, ointments,
creams, inhalers etc.):

Did you bring your medication list or pill bottles (vials) with you?

NO.OF DATE MISSED

TIMES
MEDICATION NAME DOSE ROA INDICATION SIDE EFFECTS DOSE
PER STARTED STOPPED (if any) (how many
DAY DATE DATE times)

Are there any prescription medications you have that you are not taking?

Are there any prescription medications you (or your physician) have recently added, stopped or changed?
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DEPARTMENT OF PHARMACY PRACTICE, MLR INSTITUTE OF PHARMACY

 PATIENT MEDICATION HISTORY INTERVIEW FORM
Do you think your current medications are benefiting you?

HERBAL MEDICINES / HOME REMEDIES:

COMMUNITY PHARMACY:

Do you have a pharmacy that you normally go to? (Name and Location):

Do you get your medications from more than one pharmacy?

OTC (OVER THE COUNTER) MEDICATIONS:

What medications do you take that were not prescribed by a doctor?

What medicines would you usually take for?

HEADACHE / ACHES / PAINS:

ALLERGIES:
STOMACH UPSET:
REGULARITY:
SLEEP:
OTHERS (if any):

What questions or concerns do you (patient) have?

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REPORT:

DEPARTMENT OF PHARMACY PRACTICE, MLR INSTITUTE OF PHARMACY