PATIENT HISTORY FORM

Name: _____________________________________________________________ Date:__________________

Mailing Address: ___________________________________________________________________________
Social Security Number: ______________________________ Phone: (H)______________ (W)____________
DOB: ________________________________ Height:________Weight:________FIR:________BP:________
Gender:_____________________ Pregnancy Status:_______________________________________________
Allergies:__________________________________
Reactions:_________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Devices/ Alerts: ____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Name/ Strength

PRESCRIPTION MEDICATION HISTORY

Start
Stop
Directions
Physician
Date
Date

Purpose

Effectiveness

NONPRESCRIPTION USE: Check conditions for which you have used a nonprescription medication.
________headache
________drowsiness
________heartburst/GI upset/gas
________eye/ear problems
________weight loss
________vitamins
________cold/flu
________diarrhea
________herbal/ products
________allergies
________hemorrhoids
________organic products
________sinus
________muscle/ joint pain
________other:______________
________cough
________rash/itching/dry skin
________sleeplessness

Name/Strength

NONPRESCRIPTION MEDICATION HISTORY

Directions
Purpose
How Often

Effectiveness

PATIENT HISTORY FORM CONTINUED

MEDICAL PROBLEMS: Have you experimented, or do you have: (circle Y or N)

known kidney problems?
frequent urinary infections?
difficulty with urination?
frequent urination at night?
known liver problems/hepatitis?
trouble eating certain foods?
nausea or vomiting?
constipation or diarrhea?
bloody or black bowel movements?
abdominal pain or cramps?
frequent heartburn/indigestion?
stomach ulcers in the past?
shortness of breath?
coughing up phlegm or blood?
chest pain or tightness?
fainting spells or passing out?
thumping or racing heart?

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N

sores on legs or feet?

known blood clot problems?
leg pain or swelling?
unusual bleeding or bruising?
anemia?
throid problems?
known hormone problems?
arthritis or joint problems?
muscle cramps or weakness?
memory problems?
dizziness?
hearing or visual prblems?
frequent headaches?
rash or hives?
change in appetite/taste?
walking/balance problems?
other problems?

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N

MEDICAL HISTORY: Have you ever or any blood relative had: (mark all that apply)

high blood pressure

asthma
cancer
lung disease
depression
diabetes

self
___
___
___
___
___
___

relative
___
___
___
___
___
___

self
relative
heart disease
___
___
stroke
___
___
kidney disease
___
___
mental illness
___
___
substance abuse
___
___
other____________________________

SOCIAL HISTORY: Please indicate your tobacco, alcohol, caffeine and dietary habits.
Nicotine Use
______never smoked
______packs per day for______years
______stopped______year(s) ago

Caffeine Intake
______never consumed
______drinks per day
______stopped______year(s) ago

Alcohol Consumption
______never consumed
______drinks per day for______years
______stopped______year(s) ago

Diet Restrictions/Patterns
______never consumed
______drinks per day
______stopped______year(s) ago

OTHER INFORMATION/ COMMENTS:

PHARMACEUTICAL CARE HISTORY FORM

Pharmaceutical Care History
Name:_____________________________________________
Date:_______________________________
Allergies: (include medicines and foods)___________________________________________________________
_______________________________________________________________________________________
Unwanted Medicine Effects in the Past:__________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Smoking History:
______ never smoked
_______ stopped smoking
______ packs per day for___________________ years
Alcohol History:
______ never dranks
_______ stopped drinking
______ drinks per day for___________________ years
Other drug use: (caffeine, marijuana, etc) _________________________________________________________
_______________________________________________________________________________________
How many meals do you eat each day? _______________________________
What special food or diet restriction do you have? ______________________
Height: ___________________________ Weight: _____________________
Family History:
Have you or any blood relative had: (mark all that apply)
alcoholism
___
___
asthma
___
___
cancer
___
___
depression
___
___
diabetes
___
___
heart disease
___
___
lung disease
___
___
Present Medical Problems:
Have you experimented, or do you have: (Circle Y or N)
known kidney problems?
Y N
frequent urinary infections?
Y N
difficulty with urination?
Y N
frequent urination at night?
Y N
known liver problems/hepatitis?
Y N
trouble eating certain foods?
Y N
nausea or vomiting?
Y N
constipation or diarrhea?
Y N
bloody or black bowel movements?
Y N
abdominal pain or cramps?
Y N
frequent heartburn/indigestion?
Y N
stomach ulcers in the past?
Y N
shortness of breath?
Y N
coughing up phlegm or blood?
Y N
chest pain or tightness?
Y N
fainting spells or passing out?
Y N
thumping or racing heart?
Y N

stroke
___
___
high blood pressure
___
___
kidney disease
___
___
mental illness
___
___
other conditions ____________________________
__________________________________________
__________________________________________

sores on legs or feet?

known blood clot problems?
leg pain or swelling?
unusual bleeding or bruising?
anemia?
throid problems?
known hormone problems?
arthritis or joint problems?
muscle cramps or weakness?
memory problems?
dizziness?
hearing or visual prblems?
frequent headaches?
rash or hives?
change in appetite/taste?
walking/balance problems?
other problems?

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

All information is confidential. Thank you for completing this form. We will use it to better take care for you
Copyright 1994, Iowa Center for Pharmaceutical Care

N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N

MEDICATION HISTORY AND MEDICAL HISTORY FORM

Name ___________________________ Sex______ Brith Date_______ H:____ W:____ LBW______ Rate______
1. Data Collection
Interview Start__________ Sup__________
Collected By: __________________________________________ Date: _______________________________
Prescribed Medications
Name/ Strength

Dose

Duration

Purpose

Efficacy

ADRs

Dr

Prescribed Medications Not Currently Taking or Historical Medications

Name/ Strength

Dose

Duration

Purpose

Dr

Why Not Still Taking

Common

MEDICATION HISTORY AND MEDICAL HISTORY FORM (CONTINUED)

History Collection Form, Page 2 Patient Name ____________________________________________________

Nonprescription Medications
Name/Strength

Dose

Duration

Purpose

Efficacy

Completion of nonprescription medication history

What do you take for the following conditions?
(enter on OTC list, ask follow-up questions)
headache
eye or ear problems
cold/ flu
allergies
sinus
cough
sleeplessness
drowsiness
weight loss
heartburn/stomach upset/gas
constipation
diarrhea
hemorrhoids
muscle or joint pain
rash/itching/dry skin/skin problems
vitamins/minerals
herbal products/home remedies/health food store products
natural/organic products
other
caffeine
alcohol
tobacco
illicit drugs

ADRs

Dr

Comment

MEDICATION HISTORY AND MEDICAL HISTORY FORM (CONTINUED)

History Collection Form, Page 3 Patient Name ____________________________________________________

What medication allergies do you have?
(drug name, type of reaction)

What environmental allergies do you have?

What type of adverse (bad) reactions have you had to mediactions in the past?
Compliance assessment
Base questions on history obtained in this pont.
Your medication regimen sounds complex and must be hard to follow, how often would you estimate that you miss
a dose? Everyone has problems with following a medication regimen exactly as written. What are the problems
you are having with your regimen?

Payment/Reimbursement Issues
How much a problem are medication/treatment costs?

Completion of Medical History

What other diagnoses (conditions) do you have that we havent already covered?
Diagnosis

Onset Date

Comments

Which problem are currently active, or still a problem for you?

PHARMACEUTICAL CARE DATA SHEET

Pharmaceutical Care Data Sheet

Date: ____________________________
Pt. Name ________________________

R. Ph. __________________________

_________________________________

Allergies ________________________
________________________________

Medications:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

Drug Therapy Problems:

______
___________________________________________________________
______
___________________________________________________________
______
___________________________________________________________
______
___________________________________________________________
______
___________________________________________________________
Notes:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Follow-up: ________________________________ Recorded:__________________