CHECK LIST PATIENT COUNSELING

Introduction
Greet patient
Private/ confidential
Identify self
State time factor
Other

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

Information Gathering
Current medication
Past medication
OTC/ herbs
Allergies
Signs/ symptoms
Lifestyle
Other

0
0
0
0
0
0
0

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

Medication Counseling
Name of drug(s)
Strength
Total dispense/ repeats
What medication is for
Special instructions
Side effects
Other

0
0
0
0
0
0
0

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

0
0
0

1
1
1

2
2
2

3
3
3

Conclusion
Ask patient to repeat
Clarify question
Offer to answer question
Other

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

Non Verbal
Posture
Eye contact
Manner
Facial expression
Other

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

Interaction storage
Interaction with food
Storage
Interaction with other
drugs
Other

Other
TOTAL POINT(S):

Other criteria that will help

improve counseling