MEDICATION HISTORY ASSESSMENT FORM CP 1

PHARMACY DEPARTMENT, HOSPITAL…………………………………………………………………….

FORM TO BE FILLED BY THE PHARMACIST UPON PATIENT ADMISSION

A: PATIENT BIODATA

Full Name : _______________________________________________________ B: REASON FOR ADMISSION

Gender : M/F Age : __________________

RN/IC : _______________________________________________________

Address : _______________________________________________________

______________________________________ Phone No : ________________

Admission Date/Time : ________________________________________________________

Ward/Bed : _______________________________________________________ C: ALLERGY & ADVERSE DRUG REACTION

PMHx : _______________________________________________________

Last Discharge / : ________________________________________________________

Review Date

D: DRUG HISTORY
Patient’s own drugs checked? Source of medication list :
Yes No

WRITE C FOR
BALANCE
CONTINUE,
MEDICATION FROM
DOSE FREQUENCY DC FOR COMMENTS
(Specify strength) PREVIOUS
DISCONTINUE,
SUPPLY
WH FOR WITHOLD

NON-PRESCRIPTION MEDICATION
REASON FOR TAKING BALANCE/COMMENTS
(Includes Herbal/Vitamin/Other Supplements)

E: PHARMACIST NOTES

Pharmacist Sign & Stamp : _________________________________ Time / Date : ________________________

Original : To be kept in patient’s folder

Duplicate : To be kept by Pharmacy
Pin. 1/10
 COMPLIANCE ASSESSMENT
(Choose either A or B)

A. ‘8-items Morisky Medication Adherence Scale’

You indicated that you are taking medication for your health problem. Individuals have identified several issues regarding their
medication-taking behavior and we are interested in your experiences. There is no right or wrong answer. Please answer each
question based on your personal experience with your medication. Interviewers may self identify regarding difficulties they may
experience concerning medication-taking behavior. (Please circle the correct answer)

No Question Answer

1 Do you sometimes forget to take your pills? Yes (0) No (1)

2 People sometimes miss taking medications for reasons other than forgetting. Thinking over Yes (0) No (1)
the past two weeks, were there any days when you did not take your medicine?

3 Have you ever cut back or stopped taking your medication without telling your doctor Yes (0) No (1)
because you felt worse when you took it?

4 When you travel or leave home, do you sometimes forget to bring along your medications? Yes (0) No (1)

5 Did you take your medicine yesterday? Yes (1) No (0)

6 When you feel like your disease is under control, do you sometimes stop taking your Yes (0) No (1)
medicine?

7 Taking medication everyday is a real inconvenience for some people. Do you ever get Yes (0) No (1)
hassled about sticking to your treatment plan?

8 How often do you have difficulty remembering to take all your medication? Never/ Rarely …. (1)
Once in a while… (0.75)
Sometimes ……. (0.5)
Usually ………… (0.25)
All the time ……. (0)
Please refer manual for scoring.
(<6) Low-adherence (6 to <8) Medium adherence (8) High adherence SCORE

B. Pill/ Tablet counts

Compliance score is calculated according to the formula:

Compliance score = No. of tablets dispensed – No. of tablets not taken x 100%
Correct no. of tablets should be taken

Compliance score = ( )–( ) x 100% = _____________

( )

*Compliant to medication when score is ≥ 85%