GITAM SCHOOL OF PHARMACY

RUSHIKONDA
VISAKHAPATNAM-530045

PATIENT’S INFORMATION
NAME: AGE:
SEX:
ADDRESS: PHONE NO.:

QUESTION-FORMAT
CLOSE-ENDED QUESTIONS OPEN-ENDED QUESTIONS
Allergies
What medications do you take at home?
Alzheimer’s/dementia ___________________________________
Asthma
What is the dose?
CHD
___________________________________
COPD
Depression What medications do you take every day?

Diabetes type I ___________________________________

Diabetes type II What medications do you occasionally take?
Epilepsy
___________________________________
Heart Failure
Hypertension When was the last time you took each of your

Parkinson’s disease medicines

Do you use an inhaler (or other Yes ___________________________________

medications that are not available
as pills, such as eye drops, creams, Have you recently started, stopped, or
No
injections, nasal sprays, patches, changed the medications you take? How so?
and so on)?
___________________________________

DESIGNED BY: ILYASU UMAR JIBRIL

ROLL NO. : VU22PHAR0100180