Medication History Interview

form
Demographic Data :

Patient’s Name: Male/Female:

Consultant: Ward:
Admission Date: Interview Date:

1.PRESCRIBED MEDICATION:-(What medicines are you having at the moment?)

A)Record here what the patient says, noting any anomalies with their current prescription.
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B)Other drugs prescribed previously(with date if possible):- what have you had in the past?
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2.NON PRESCRIBED MEDICATION:-Do you take anything that you buy from a shop without a
prescription-chemist, health food stores, super market?
A)Currently being used:
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B)Used previously(with dates if possible):
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3.SOCIAL DRUGS – Ask what and how much/many per week?

A)Smoking:
B)Alcohol:
C)Illicit Drugs:

4.Response to Drug Therapy -

A)Do you think your current medication is benefiting you?
If yes, how?
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If no, why?
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B)Do you think your previous medication benefited you?
If yes, which ones and how?
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If no, why?
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5.Do any of the things you buy without a prescription, helped you?
If yes, how and which ones?
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6.SIDE EFFECTS:
A)Are you suffering any side effects now? If yes, what side effects.
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B)Which of your medicines do you think is causing the problems?
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C)Have you suffered any side effects with previous drug treatments?
If yes, what side effects and with which medicines?
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7.COMPLIANCE:
A)How do you remember to take your medication?
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B)What do you do when you miss a dose?
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8. What medicines would you usually take for:

A) Headache:
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B) Aches/Pains and Flu:
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C) Allergy:
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9. Who would you ask for medicines for Headache, Allergy, Flu etc :
A) Pharmacist/Chemist:
B) Relative or Friend:
C) Nurse:
D) Doctor:
E) No-one:

10. Any other problems with Drug Therapy?

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11.Comments:
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12.Recommendations:
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Signature of Pharmacist