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Consent

Name, DOB, Occupation:

Current medical conditions (on-going medical problems)

Allergies (Sensitivities and describe the event)

Smoking, Drinking and Recreational drugs

Have you brought all your medicines? If no  prescription or empty boxes

Name, form, Frequency Reason Duration OTC/prescribed


strength

Drug:

 Why are you taking this medicine?


 When was it started?
 How often do you take this drug?
 When do you take this drug?
 Do you regularly take this medicine?
 Have you experienced any side effects?

Do you feel you need these tablets?

List all drugs and concordance

Recommendations and concordance for every drug

1. Concordance
2. Interactions
3. Side-effects
4. Stop/Increase or Decrease/change drug

Eg

Atenolol 50mg

1. Not taking daily and does not know why taking it


2. ? Stop betablockers
3. takes beta agonist inhaler for asthma

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