Introduction (10 %)

Greet patient 0/1 Identify self 0/1

Privite/Confidential 0/1 State time factor 0/1
Other 0/1

Information Gathering (20 %)

Current medication 0 1 2 3
Past medication 0 1 2 3
OTC/Herbs 0 1 2 3
Allergies 0 1 2 3
Preg/Lac 0 1 2 3
Signs/Symptomps 0 1 2 3
Lifestyle/Triggers 0 1 2 3
Others 0 1 2 3

Medication Counseling (25%)

Name of drug(s) 0 1 2 3
Strength 0 1 2 3
Direction 0 1 2 3
Total dispense/Repeats 0 1 2 3
What the medication is for 0 1 2 3
Special instruction 0 1 2 3
Side effects 0 1 2 3
Other 0 1 2 3
Other 0 1 2 3

Interaction/Storage (20 %)
Interaction 0 1 2 3
Storage 0 1 2 3
Interaction 0 1 2 3
Other 0 1 2 3

Conclusion (10%)
Ask patient to repeat 0 1 2 3
Clarify Question 0 1 2 3
Offer to answer question 0 1 2 3
Thank patient 0 1 2 3

Non verbal (15 %)

Posture: 0 1 2 3
Eye contact
Manner
Facial expression
Other

Other Other criteria that will help improve counseling 0 1 2 3

TOTAL POIN(S)

Keterangan :

0 = tidak menyebutkan sama sekali/tidak melakukan sama sekali

1 = menyebutkan tapi salah/melakukan, tidak baik

2 = menyebutkan tapi kurang tepat/melakukan, cukup baik

3 = menyebutkan dengan benar/melakukan dengan baik