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    Patient Medication History Interview

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    razeghi
    This document contains a patient medication history interview form used to collect information from patients admitted to the hospital. The form collects demographic information, chief complaints, medical history, social history including smoking, alcohol, and diet. It documents recent hospitalizations, prescription medications including indication, duration, last dose, and any problems. It also documents known drug allergies and the data sources used to complete the form. The interviewer signs and dates the completed form.

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    Patient Medication History Interview

    Uploaded by

    razeghi
    16 views3 pages
    This document contains a patient medication history interview form used to collect information from patients admitted to the hospital. The form collects demographic information, chief complaints, medical history, social history including smoking, alcohol, and diet. It documents recent hospitalizations, prescription medications including indication, duration, last dose, and any problems. It also documents known drug allergies and the data sources used to complete the form. The interviewer signs and dates the completed form.

    Original Description:

    MHI Form for patient anlysis

    Original Title

    MHI_FORM

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    This document contains a patient medication history interview form used to collect information from patients admitted to the hospital. The form collects demographic information, chief complaints, medical history, social history including smoking, alcohol, and diet. It documents recent hospitalizations, prescription medications including indication, duration, last dose, and any problems. It also documents known drug allergies and the data sources used to complete the form. The interviewer signs and dates the completed form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    16 views3 pages

    Patient Medication History Interview

    Uploaded by

    razeghi
    This document contains a patient medication history interview form used to collect information from patients admitted to the hospital. The form collects demographic information, chief complaints, medical history, social history including smoking, alcohol, and diet. It documents recent hospitalizations, prescription medications including indication, duration, last dose, and any problems. It also documents known drug allergies and the data sources used to complete the form. The interviewer signs and dates the completed form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Department of Pharmacy Practice,

    PATIENT MEDICATION HISTORY INTERVIEW


    PATIENT DEMOGRAPHICS:
    Name: _______________________Sex: M/F (Pregnancy status :____) Date of admission:___________
    consent
    Hospital no: _____________ I.P. No.________________ Age: _______ Weight:_______ (Kg)
    ___
    Ed. qualification: Illiterate

    Inter

    PUC

    UG

    PG

    Ht (m):

    Patient
    __ BMI:

    Occupation: _____________Languages known/

    conversant in:__________
    CHIEF COMPLAINTS ON ADMISSION:

    Ant-acids
    OCPs
    Medical history/ surgeries:

    Cough
    Nutritional Herbal
    Topical
    Social history
    Duration
    syrups
    Suppleme
    suppleme
    medicatio
    nts/
    nts
    n
    Smoker(pack/years)
    Vitamins
    Alcoholic

    Vaccinatio
    Diet
    n status

    Alternate
    system of
    medicine

    Tobacco chewing
    Snuff
    Others
    No habits
    Analgesics
    Ayurveda
    Homeopathy
    Unani
    Siddha

    RECENT HOSPITALIZATION: Yes

    No

    No. Of hospitalizations in the past month:


    Reasons for these hospitalizations:
    Duration of most recent hospitalization:

    MEDICATION HISTORY CHART FOR PRESCRIPTION MEDICATIONS


    Date

    Medication and Frequency with


    Strength

    Indicati
    on

    Duratio Last dose Any


    drug
    n
    taken on: problems/ADR/ ADE

    related

    Date

    Medication and Frequency with


    Strength

    Indicati
    on

    Duratio Last dose Any


    drug
    n
    taken on: problems/ADR/ ADE

    related

    DOCUMENTED DRUG ALLERGIES


    Drug

    Date of
    allergy

    Brief description of the allergy

    Data sources referred to:


    Patient

    Patient party

    Prescriptions

    Patients
    medication

    Case file

    Discharge
    summary

    REASONS FOR NOT INTERVIEWING THE PATIENT:


    ________________________________________________________________________________________________________________
    __________________________________________________________________________________________________
    ASSESSMENT OF COMPLIANCE BEHAVIOUR

    Interviewers Signature with date

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