Medication History Checklist

Check

Allergies
List medication/ food allergies
Adverse Effects
List adverse effects as described by patient
List abnormal laboratory findings
List documented adverse effects
Current Medications
List current medications
Indication, dosage, schedule, duration, outcome
Quantify use of PRN medication
Past Medications
List past medications
Indication, dosage, schedule, duration, outcome
Why was drug discontinued?
Non-prescription Medications
OTC, CAMs, vitamins, minerals, other supplements
Other Medications & Immunizations
Medication samples
Immunization History
Medication Experience
Individuals subjective experience of taking a medication
Medication Adherence
How medication prescribed vs. how actually taken?
How often in a week does patient miss a dose of medication?
What is the system used to manage/remember medication?
Reasons for nonadherence
Other Medication Considerations
Concerns with cost of medication

YES NO