Medication History and Medical History Form, w Sex BithDate BW Rae Name Tniawiew Sa Te I. Data Collection Collected By: D Prescribed Medications Nee aca [Base [Duration [Fupore [Effaey [ADRs [Dr (Comment Prescribed Medications Not Currently Taking or Historical Medications Daag Doss [Daraton [Purpose [De Way Na Su atingNonprescription Medications ‘Nae Seng [Doe [Duration [Purpose [Eicaey [ADRs Dr Comment Completion of nonprescription medication history ‘What do you take for the following conditions? (enter on OTC list, ask follow-up questions) headache cold/flu allergies simus cough sleeplessness drowsiness ‘weight loss heartbum/stomach upset/gas constipation diarrhea hemorrhoids muscle or joint pain rashvitching/dry skin/skin problems vitamins/minerals herbal products/home remedies/health food store products natural/organic products other caffeine alcohol tobacco illicit drugs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 medications in the past? Compliance assessment Base questions on history obtained to this point. ‘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? PaymentReimbursement Issues How much of a problem are medicationtreatment costs? Completion of Medical History ‘What other diagnoses (conditions) do you have that we haven't already covered? Diagnosis Onset Date ‘Comments Which problems are currently active, or still a problem for you? Perist ROS