Patient Work-up (SOAP) Form

Name: Type of Initial Follow Up Final

Visit
Date: Study Pharmacist:
Code:

Subjective:

Objective:
(use data flow chart for lab
tests, etc., list medications)

Assessment:
Include adherence to
diet, exercise, and
medication.

Plans:
Goal set with patient
for next visit.

Follow up
(for: date of next visit)
 PHARMACIST CONSULTATION FORM
Date: ____________________________ c If checked, this form must be reviewed by the patient's physician before placing in patient file.

Patient: _______________________________________________________ Phone: H ________________________ W ______________________

(last) (first) (ml)

Address: _______________________________________________________________________________________________________________

Birthdate: _______________________________________ Age: __________ Member No. __________________________________________

Height:__________________ inches Weight: __________________ Ib Member Group No. ______________________________________

Sex: F ____ M ____ Pregnant: Y ____ N ____ Referring Physician ______________________________________________________________

Physician Provider No. _____________________________________________________________________________________________________

Past Medical History:

c Asthma c Ear Infections c Hay fever c Liver disease c Other _____________________________
c Cancer c Epilepsy c Hypertension c Thyroid disease c Other _____________________________
c Diabetes c Glaucoma c Kidney disease c Ulcer c Other _____________________________

Drug Allergies:
Drug When Explanation Drug When Explanation
c Penicillin _____________ _____________________________ c Sulfa _____________ _____________________________
c Other _____________ _____________________________ c Aspirin _____________ _____________________________

PrescriptionMedications Currently Taking:

(indicate if prn)
Drug Strength Sig Compliance% Last refill date Drug Strength Sig Compliance% Last refill date
____ _______ ___ ____________ ___________ ____ _______ ____ ____________ ____________
____ _______ ___ ____________ ___________ ____ _______ ____ ____________ ____________
____ _______ ___ ____________ ___________ ____ _______ ____ ____________ ____________
____ _______ ___ ____________ ___________ ____ _______ ____ ____________ ____________

OTC Medications Currently Taking: ____________________________________________________________________________________________

Subjective: How is your asthma/breathing? _________________________________________________ Correct use of:

How do you feel? ____________________________________________________________ MDI (Yes-No-N/A-)
Any New Complaints? ________________________________________________________ Extender(Yes-No-N/A-)
Any problems with your medications? ____________________________________________ Nabulizer (Yes_No_N/A-)
Notes: ____________________________________________________________________ PEFM (Yes-No-N/A-)

Objective: Serum levels of theophylline: Started

Level _______ meg/ml Date/time: ____________ New Rx medications _____________________ ______________________
Last drug, dose and time before level: __________ since last visit) _____________________ ______________________
Temp___ Pulse___ Resp___ B/P___ PEFR ___ New OTC medications _____________________ ______________________
since last visit) _____________________ ______________________

Assessment: _______________________________ Referred to Immediate Medical Care (_____________)

______________________________________________
______________________________________________
Plan: Goal/Desired Outcome/Basis of Recommendation: ____________________________________________________________
___________________________________________________________________________________________________________
Action Taken: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Recommendation(s):__________________________________________________________________________________________
___________________________________________________________________________________________________________
Follow-up:
Next scheduled visit (within 30 days; at refill time if possible) Date: ___________________________________ Time: ________________________
Prepared by: (print) __________________________________ Signature: ______________________________ Phone: _______________________
Pharmacy: _________________________________________ Address: ________________________________ NABP#: ______________________

McCallian DJ, Carlstedt, BC, Rupp MT. Caring for the Asthma Patient in a Community Pharmacy,
Monograph 11. In: Value Added Services Series, Rupp MT, ed., Washington, DC:APhA;1994:10.
 ANTICOAGULATION PROGRESS FORM
Date:_________________________________
Patient ID: ____________________________ Age: _________
Race: ________________________________
Allergies: _____________________________ Height: _______
Weight: ______________________________
Indication f or Anticoagulation: ________________________________________________________________________
Desired INR range: _____________________ Est. duration of therapy: ________________________________
Other medical conditions: ____________________________________________________________________________
Current anticoagulation dose:_________________________________________________________________________
Last dose taken at: _________________________________________________________________________________
Compliant to current dosage?: c yes c no
Compliance method used: ___________________________________________________________________________
Other medications: _________________________________________________________________________________
Any new medicines* since last visit?:
Antibiotics?: c yes c no OTCs?: c yes c no
Flu shot?: c yes c no NSAIDs?: c yes c no
*Remind patient to contact MD or pharmacist before taking any new meds.
Alcohol intake: ____________________________________________________________________________________
Smoking: _________________________________________________________________________________________
Recreational drug use:_______________________________________________________________________________
Changes in dietary intake:____________________________________________________________________________
Any symptoms of the condition the anticoagulation therapy is being used for?: __________________________________
_________________________________________________________________________________________________
Any signs of bleeding?:
c Unusual bruising.
c Nosebleeds, bleeding from gums.
c Unexplained pain or swelling.
c Increased menstrual flow.
c Discoloration of urine and feces.
Any adverse drug reactions?: ________________________________________________________________________
Any other nonspecific complaints?: ____________________________________________________________________
Today's PT: _________________ Time of test: ___________________________________________INR: ___________
Comments: _______________________________________________________________________________________
B.P.:_________________/___________________ H.R.: ____________________ Temp: _______________________
Is the anticoagulation therapy providing the desired therapeutic outcomes?: c yes c no
Comments:_______________________________________________________________________________________
Recommended dosage (after discussion with prescriber): ___________________________________________________
Other actions taken:_________________________________________________________________________________
Next appointment:__________________________________________________________________________________
Pharmacist__________________________________________________________ Date: _______________________

McCurdy M. Oral Anticoagulation Monitoring in a Community Pharmacy, Monograph 12. In: Value Added Services Series, Rupp MT, ed., Washington,
DC:Al'hA:1995:11