Patient Name:

Subjective
CC:

Objective
Physical Assessment
Findings:

DOB:
Assessment

SOAP GRID Form

Age:
Plan

Primary Problem(s):

Sex:

Wt:

Ht:

Goals of Treatment:

HPI:

Pharmacologic Therapy

Non-Pharmacologic
Therapy

Drug name(s), strength, dose, route, dosing frequency, duration of therapy

General Care/ Preventive

Measures

Medication Counseling for above choice(s)

(key points)

Alternative
medications/vitamins/
minerals

Exclusions for Self-Treatment:

H
Treatment Options:
( with Pros/Cons)

Test Results:

OTCSOAP-GRID-SPPS201-202Fall14-W15

Three Prime Questions- What is it for, How to take, What to expect (i.e. what
symptom are you treating, how it works, dose and frequency, length of Tx,
expected time to onset of relief, most common side effects and management,
when to see MD, storage)

A
R

Medications:

__________________
Potential Causes:
(Rule In/Out):

Allergies/ADRs:
PMH:
SH:
Tobacco
ETOH
Dietary habits
Exercise
Occupation
Exposure
Other

OTCSOAP-GRID-SPPS201-202Fall14-W15

Drugs/Factors To Avoid:

Symptom(s) you are

treating, medication
name(s), strength, dose,
dosing frequency, , length
of Tx, expected time to
onset of relief, most
common side effects and
management, potential
drug interactions, when
to seek MD, storage)