INTEGRAL UNIVERSITY

FACULTY OF PHARMACY
LUCKNOW

Medication History Interview Form

(Pharm.D. Internship)
I Demo 0 rnphk :md Social Information
Pntient Ir N0:)o,f5!? r\ge -
36 V 1r IC cndi:1 Ir mole I k1~h1 1Weight
Religion If i'nd(t., ] (krupntio11 - l "'('gnant \ l'~ 01.No Brea~! fcccl1ng Y c~ o~ No

2) C'hir~Complain~!_

- pain t'n 1/bJt>men x 15cfo.ys

- On/ D/F /eve;-,

3) History of Present Illness:

fls s./o.Jed bt pa·/-t'enl She ~as appQJ1e~II:;; as1/mt.lomof/c
Cono/d-ton . w/2en Jh~ c.om11fatnl~ 0/- paw 1n !lhd~mfn ono/ ,;n
4)
5) Past Surgica l History:

No H/o - I-ITN, TB, Dftl

6) Past Medication History: 7) Family History:

ND M~J,cak87) H,slo~ IV I g
8) Immunization History:
Immunization Type Date last Received
lnfluenza

Teta11us
Ill/ .&Jne
BCG
Others:

9) Allergies (Medication and Food) /Adverse Reactions:

No. Product Name Type and Severity of Reaction

None
 " fions
-JO) Curre nt Prescription M ed 1ca --- --- - Root< nf Days
Drug Braud Name Gener ic Nnrne lndiu tion Oo~c Admln
Freq
~
l 2 J 4 5 6 7

llh.tnMedalb-le __ J/11/.iZia./ic
I .__..
~rl; 1JopmJ ,_Q _~ 7M 1,/ \ / ._/ v ✓

I I -
- -,~ -
IT. '%,w,.,,./,./ fir, Pl''IYJ-1 H#q
IJ. t. t. NSJJJD __ I -- _{J._ - /IJJ
LV, ,--- ~-- ......-- .__...,,,.

I .
<1....... .. :11Jflfr1JL - -· -
r ~,,.n 1/11 l'IA, JA/A 9l/lu le. lJ_fasbic f c_~-Y-~fn<J ._( J_ /JI\ ,~· V I/
._, v v

I - - ,_ - >--
..., ..,. .
7· I} ../11 7 M,, II, w.fam1_ ?/?~ne !JeMJ.~-
' I-
() -~QD • 1 - ,...--
·-- -

I I

II
ts
s/Herbal/Nutritional products and supplemen
11) Curr ent Non-Prescription Medication D s
Route of Freq
Indication Dose admin I 2 l 4 5 6
Dru!? brand name Gener ic name

Compliance
12) Asses smen t of Outp atien t Medication
administration for this patient?
a) Who is responsible for medication
?
ing or complying with medication instructions
b) Does patient have any difficulty understand

c) Barriers to medication adherence? ifyes

explain:

13) Diet and Exer cise

a) Typical daily diet: Hb'1e /J,J, Yes( ) No( )(explain)
)?
b) Able to conduct Activities of daily living (ADL
14} Personal Habits (Smoking, Alcohol)
Alcoh ol
Smok in2 l use: /week;
a) Never smoked V'"fq uit smoking ( ): When: ► No use V]S ocia
Quantity:
b) How long did they smoke? __ Years
/week;
c)Smokes _ _ packs/day ► Regular use:

d) Exposure to second hand smoke _ _ ► Quantity:

hours/day

~¥ittt
Name & Sign. of Student
 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW

Medication History Interview Form

'"
·71
1 Demo ra hie and Social Information
(Pharm.D. Internship)

Patient IP No: qqo8 Age 21.f ye_(J)(J. Gender r(!.mO ~ Height Weight

.,. Religion Mus /m Occupation - Pregnant: Yes or No_ Breast feeding: Yes or No
~ ~

2) Chief Complaints
~

pow m 4/Jdom~n x I we~k

"
~ F"euv1. vn /of I- x L/ kJ/.).
~
3) History of Present Illness:
~
polt'enf- Mme CJ-IIA d,~ eemtlain¾ oJ !he pa tn 1:_ 4t t/omfn g111' ce
~
_,week (!tfl cf. sAe ofso com h/nl~ Qj lh e ~UfJ't on /o {/:- f ?1om 'f cla 1
1' 4) Past Medical History: 5) Past Surgical History:
I

I'\ "I l .~ / 1
1w ()llli:J'~:t1c r/ 1.s1~7
1
"" 6) Pbst Medication History:
-----
1-·umil~ History:
7)

"' Io t1 )

8) _ Jn11nuni1.11lio11 ll_iN_to_r.;..y:_ _ _ _ _ __

l,m11m11'-:.arimt Type•

ln11ucnza

1\,tmms
----------- -+--------
f)o N r.
-,-------i
-------------f -...;;;,...~~-- --"'"1'------1
RC'G
Others:

9) ..\llttaits (l\ltdkation and Food) /Ad,·tne, RHction.s:

No. Product Name- Type and Severity of Reaction
 p res cri pti on Me dic ati on s
,-1O) Current Ind ica tio n Dose
Rou tt- of
...\d min
Fre q.
Oa~ s
4 ~ 6 7
Ge ner ic Na me 2 3
Dr ug Br an d Na me
I

h,,.m 1,1 . I".- ,, / v' \/ Vv

J n r P/nYl'I I~ l'Y) II/ ~"- v ,_.,. ~ vv V

7X r !Yl~nlltPf ln ~m f IV 11'\C!_ \ vi v V V

lTn~ M~l._,,..o •111 ... /1)( t\J ~f l \, V 1v' V" V

~U T /Jn,,,'ftr.t1 ·, ·,~ ()( I ~ IV rJ.D " 1,-

7n \ /1 ,,- - ... -· lllnn-,ry IV 7 [')Q \.. v C -

IJAir Prr-h
vV
tln f'N } IV ·1 f\Q V
'
,- V
nr - Pl)n u...) tv , ,~ c-
.,, ~ '· .... i <

l n", P m J" f'

v
v ·
1\/ n l\cnl'I~ ~
l11m~
7~, /;/ tn it~ L, ·~ I
~ ,.... (,1"

'I IV IT D \ / l./ L

-
1
1n r 1h '"';, rn
I,<,
U /;,/u If.l ii 11,.
emen s
pr od uc ts an d su pp
M ed ica tio ns /H erb al/ Nu tri tio na l Days
on
1 J) Cu rr en t No n-P res cri pti Route of Freq
I 2 3 4 5 6 7
tion Dose :idmin
Ind ica
Drug brand name Generic name

I
I I '

tio n Co mp lia nc e
Ou tp ati en t M ed ica pmic111?
12 ) As ses sm en t of 11i11istratio11 for thi.1
o is re.1po11.1ib/e /or 111edica 11011 nd1
a) Wh
/rinl! 11ir/1111eclirntio
11 i/1.\tmctio11s?
· di//ic 11/t1 111 1den1undi111! or t <1111p
h) Does patient hr11 •e am

., e1plm11
on ad h,•n•11n•.' If n
,·) Ba rri ers to me dic ati

sc plain)
JJ) Diet and Ew rd
t: Yes t- Y No ( ) (ex
a) Typical daily die ing (ADL 1?
Able to cond uct ActivitJes of daily liv
h)
l)
s (Smokin~. Alcoho Al co ho l /week;
14) Pe rs on al Habit :
, ~o u s ~ Social use
I S111okin2 oking ( ): \\.hen :
smoked v J ' quit sm Quantity
f a) Never
smoke? _ _ Years
b)How long did they , Regular use: /week;
cks da)
c)Smokes _ _ pa
,
~

Quantit) :
e __
to second band smok
d) Exposure
hours.da)
,1
 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW

M_Q.qfc.atum f:Ult91YJ.D!!.cy1tw_ FQTJD

(Plwm.n. lntNn<,hrp)
11 _!)ctl_!_Qg1·AJlhk 10111 So"lttl lt1fo1-rnaflo11
ticnt IP Nn -::,of t'I ~ Ag<· . ?() '/ft.mt$ Ocmkr /'1nl('

t
f IC'i 0 hl [ W- · hi
r-:J
l
I;
,., \ Cl!~ 1, ~

HginO ;/,n d/ 1_ <krnp•lin" r~"""'', yc«n No Brca<;1 feeding; Yes ;;-r tio
__ _J
2) Chi<1fC0111ploinh
----- -- -
- porn ,'n !llxl'omflJ ./ I
'/' f/('(.fllj f,
~ Oomc tno O1
d) .

3) History of Present Illness: fl p fJ ~ p I I

pa~if~! <UtU ()./f ().}tenlfJ_~m~~r 1 rlog.,~ oek · uJ/lc.rJ tfJ. rr~ue ~opccl \
1

patn 1n llbiomen wAich bJ0/4 su.cld~n ,n ons el--rf Pu£Jftf'Ht Vf'. ,n r1oltJ1
cl tJ.nahl~ l-o {t,q sloo{ ?( Flatw-u s/nce 3C'l J If D/s.ocfP 6{ I.Jorr,J,:,.,
=.y_,
4) Past Medical History: 5) Past Surgical History:

6) Past Medication History: 7) , Family History:

,f,'?

No MeJ/cal/en H,s/oh' low

8) Immunization History:
Date Last Received \
Immunization Type

Influenza 7
Tetanus
_j
I Done
BCG

Others: Cottorw,
9) Allergies (Medication and Food) /Adverse Reactions:
No. Product Name Type and Severity of Reaction

,Jone

•.

,,.
 l>o ,t ltnu tr or
fnd 1 c-A ho"
\flm 1n 7
,.

tv
u
'lam r; IV

~~ l
!tin
l
V

!!11A lJ
Jla6 0

· ple me nts
io 1 /1-1 b a 1/N u t n·t wn a pro du cts and sup
11 >sc rip tio u I:\lt >di cat IS er IJaH
> <- UITt>ut :\0 11- Prt Rou le of Freq
Ge ner ic nam e Ind ica tion Do se adm in I 2 l -+ sI I -\
Dru::: hr. ind nam e I
I
I
l I
I
I
'
I I

I Compliance
12 ) As ses sm en t of
Outpatient Medication
on f or this pat ien t?
me dic ation administrati
a) Wh o is res po nsi ble for
instru ctions?
din g or com ply ing with medication
any diffic ult y und ers tan
h) Do es pa tiem ha ve

lai n:
ad he ren ce.? Ify es exp
CJ Ba rriers to m edi cat ion

IJJ Di et an d Ex erc ise No ~ xplain )

t: Yes ( )
a ) Ty pic al dai ly die (AOL) ?
tivities of daily living
b I Ab le to con du ct Ac
(Smoking, Alcohol)
14) Pe rso na l Habits Al co ho l /week:
:
I Sm ok iltK
./
): When:
, No use '(- /' ) Social use
Ne ve r sm ok ed (., /) qu it sm ok ing ( Quantity :
a)

sm ok e? _ _ Years
bJ Ho w lon g did the y
,' /week;
Re gu lar use :
c)S mo ke s _ _ pa
ck s/d ay
',, Qu ant ity :
on d ha nd sm ok e _ _
d) Ex po sur e to sec
ho urs da y
I
 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW

Me di catlon..l::ll112JyJn.tJH:v~w Form
---
(Phann.D lntcrn .-.hrp)

1) Or111o ~ afhfr an,I ~odal lnforn rntlon

Pa1icnt IP No Of 1611 \ gc l/ 7 Yc1t 't~t ,cndl'1 /'r/n/e fl c1~h1 - I Weight

Breast feed ing Yes or 1'.o

Rchg i0,;-I ( 1 n cfll Occup ; llrn~ .,. J_:cgna111 Ycs CH ~ 1

2) Chie fCom pl:iin ts

1
fo.t n in 1/bdo mfl l 1' !m on/1, I
I
\
3) History of Present Illness:
poh'Pnl ap/()J-tenf~ aJyrnploma!r'c J monM 6ock DJA en. Ar::.
(JJM
i
(}'1/f:Cf.(encrd tmn in RiJAI sicle. !l/Ji9mtJl1 uurno&w ffJi
f JCOf ,ec;.s1 ve\
m nalw,e 5) Past Surgical History:
4) Past Medical History:

None.,
No /Y/eJc'c.a[ f/1~fo1~
i 7) Fami ly History:
6) Past Medication History:

!Vo /YJf!lcalrrm H,s./o9~ N/S

8) Immunization History:
' Immunization Type
Date last Received

Influenza 7
Tetanus I (}tJne
BCG J
Others: lb J{_() n..c'L
rse Reactions:
9) Allergies (Medication and Food) /Adve
Type and Severity of Reaction
No. Product Name

/\Inn"'
'""
,,..._

/III) f 111 n•nf l'n-~ 11 iplion !\Jrd11 .1111,n ~

Homr •'
u.. ,,
Ila " I: 111•11111 \ .,m r (,rn r 11r '\ un c r I"'"" hoo ll nc \, l,nln
J-r,,1

' I[ ,-, IV
""" JV
~

fl
fl
(''
10
Jbm{
2_1,pry
~ '/QlrJ
mg

i
D
0

ll.
C
Q
SoomrJ 0
~
flt I o./i;
' /1) Ii 0
fl 1.6. L
I t
l prod ucts and supp leme nts
l\ted icati ons/ Herb al/N utrit iona
11) C'ur n'nt \on- Pres crip tion Route of
!Ja,.,
Freq I-
I Dose 1 I 5 6
Indication atlmi n I 12
Drug brand name Generic name
I

ication Compliance
12) Assessment of Outpatient Med
ble/o r med icati on administration/or this patient?
a) Who is responsi
medication instrnctions?
understanding or complying with
bJ Does patient have any difficulty

e? Ifyes explain:
cJ Barriers to medication adherenc

13) Diet and Exercise

a) Typi cal daily diet: Yes ( ) No (J{. exp lain )
daily living (AO L)?
bJ Able to conduct Activities of
hol)
14) Pers onal Habits (Smoking, Alco
Alcohol
Smo kine cia l use: /week:
aJ Never smoked (0q uit smoking
( ): When: ► No use (0So
Quantity:
s
b)How long did they smoke? __ Year
/week;
c)Smokes _ _ packs/day ► Regular use:

dJ Exposure to second hand smo

ke _ _ ► Quantity:
hours/day

Sig nat ure ~ce pto r

.,41
!
-~
◄I 'I
'
~
Ali
l INTEGRAL UNIVER SITY
FACULTY OF PHARMACY
. .,....._
LUCKNO W

◄, ' Medicati on History lntervf~w Form

,....,_ {Pharm.D. Intern ship)
•
l
I

_ Dcmo_g_,_·11£!1!£ Hl!._lf Sodn l lnfon11 11 tio11

\1t1rn1 IP'-vtY~c,366j Age I/() y / (lender I f !e ight Weight

Breast feeding· Yes or No

Rcliµ,0 11 /~/r1.r/,in Occupation _ L rcgna111. Yes or~o \,

~
2) C' hiefC'omplaints
- ra(I) in llff en /lbcltJmr.n x 1yeai1
- B/oalt"nJ, X I v~a.7
- Naaua ., vomih'nJ X lo rlay~

3) Histor)1 ofPresen tlllness: , .

p-l. com~ u..•ilh chet/i eom1/alnl.~ [IJ -fhe fatn ,n /.Jhe1/omrn Dnc!
8 foa -!in.Ji since ryw• and 6/2 o com! hin/;/ u om iI,~ an/ NauJ.f a / '5 do; ~.
5) Past Surgical History:
4) Past Medical History:

Non e_

6) Past Medication History: 7) Family History:

DfYl / fYJ edl C,(J.//o n

8) Immunization History:
Date last Received
Immunization Type

Influenza

Tetanus UJtltJ~
--
BCG
Others:

9) AJlergies (Medication and Food) /Adverse Reactions·

No. Product Name Type and Severity of Reaction

.,
 ,\ h•r llrn tion ~
10) Cu rre nt Prr sni ptl on
~

Da) •
~ Rmrlr of f"r,q
f)o, r ~ S 7
(,fll<'l'ic '\nm r lndfr111ion \tln1in J 2 - 3 6
Drul! Brun,! '\11111(' ....

1J,~.{£1() /1·c l7m Iv l?h1) V ._,- v

-
\. v ✓ V

IJIJ}- llln~ a1 , &/i., enone

- ··
11 IV~ II~ ' ./I -
1lril1 'rlwlu l,'c ___ ?c -
l1\ 1 L
ln11Jl/. w _:_'JJJ mL ~, l,'Jil
,. .)}J1/L '6 /QI.tr.
1; ., I'
I '{_ _
'Sf.'...c..m7
lti~ IJ11i,'k:1n'll ~

,- J - -
fJ {J
t-

D n,li rl,n ,/l,, 1./,; ;,,n

-- f)ll /I~J!JJJJ'i.f. ~l n'l (')

17 n,1n <1 ~
pp
!hn/11 /!)., -, IP
fJ h
I
~-f - ()

·-
r✓ n I
~

1
IT 7n 1•i'/ t I CJ ro )
( I) l l'l T Toh
N_
7 '7p9,.),,/ ~1 Prm 1M ~ ~;f l I

I ~~rn l [, I/ c;
!11; n f 11 ermJ~r~
/I I
~ r - f/urnM 11 5 l.(l1h I

products and supplements

n-Prescription Medications/Herbal/Nutritional Dan
I I) Current No Route of Freq
2 3 4 5 6 ;
Dose admin I
Indication
Drug brand name Generic name

ce
tient Medication Complian
12) Assessment of Outpa inis tra tion for this patient?
sible for medication adm
a) Who is respon
medication instructions?
difficulty understan ding or complying with
b) Does patient have any

:
adherence? lfy es explain
c) Barriers to medication

13) Diet and Exercise

a) Typical daily diet:
(AOL)? Yes( ) No ( )(explain)
b) Able to conduc
t Activities of daily living
ng, Alcohol)
14) Personal Habits (Smoki Alc oho l
Smoki11 ocial use: /week;
quit smoking ( ): When: ► No use (......-tS
a) Never sm ok ed (/; Quantity:
? __ Years
b)How long did they smoke
: /week;
c)Smokes _ _ packs/day ► Regular use
r

d) Exposure to second
han d smoke ► Quantity:
hours/day

t~
Name & Sign. of Student
 u
~ st INTEGRAL UNIV ERSI TY
! ~, FACULTY OF PHARMACY
-
~ ./
Q~-~
~w,~
LUCKNOW

Medication History interview Form

(Pharm.D. Internship)

I Demo r~c and Sort1I h~orn_!!lllon

Patient IPNl,: ~9,6'{ 7 Agl' 6 /
1 YM'l Gender frJr,/(l
Pregnant : Ycs or No
Rodigion flindt t Occupation \.

2) Chief Complaints
. UlCe'l. &ue'l RtJA r J(i(l{ X !j rl.(l;;/l.,

- rnorea.recC Midtucr'lt'on t ,.,srto;s

- feuev. Yrs cf.at .f
p, /), ! , f ,f
3) History of Present Illness:
1alien!- ~ai O!f OJ/@nHi. 04 rrrlo r fiemOff C fbn{'{ I (1 lm . !J"a \ Chiet;,
fie air,
com1l0.i'n!s riJ .fhe 11/cl)(, l)UVl R1JM roof h,0m 5 rf(l).r1, llnit.
rNntil(J.l.n/1 Feve"e. and. Incm aud fVlr'c/tlhil-t'en n1om !'5 d0-1/2
5) Past Surgic al Histor y: '
4~ Past Medical History:

- No wsloc1,
7) Family Histor y:
6) Past Medication History:
0
No /Vletf.ic,liMZ His./v'hif, !ow
8) Immunization History: Date last Received
immunization Type

Influenza l
Tetanus I nnhfJ
BCG I
Others:

9) Allergies (Medication and Food) /Adverse Reactions·

No. Product Name Type and Severity of Reaction

"'f:h,ip
 ,,..... \lM\tt'\,t

·~:f
\t\ml1\
l!',lit"IH\11

A [\l
\ 19 ill
A W\~)•.Jl--·l - t-
J()r-,,'J IV
l I

I L~mQ t~ J oi_l ~
t~t1h~rr t~
~a.mJ lV !) D
i
~ tJ_pw~ 1\/
l---4---+-+-+-+-+-+--H

CGW - - J _ _ - ~~----t-L.:LIL..U--j--.1.:'.--~~~,r-r-
, t -,

ll) 1-.'u I nt '\ rr, · •ription \kdications Herba\/N11trition•1l products nncl ~upplcments oa,~
r~ ~~(

r------ - - -
(I 11 -

Indication Dose
Rout, of Freq
:idmin 1 ~ ~ 4 5\ h I'
I Drui:. t>rJnd n:inw Ccnrrk nume

I
r

I
I

' I -
'I
I
l~) Assessment of Outpatient .\ledil'!ltion Compliance
,: 'i,> :s r.:sp,n:sibi<'Jt>r 111<·dicario11 adminisrrarion for rhis parier1r:>

ti D,1,:, r,uit·nr haw any didic11/ry 1111dersra11di11g or co mply1)1g ,rirh 111edicario11 i11srrucrio11s?

c, 8.:rri.-r~ 10 m2dicario11 adherorce? /fyes explain:

13) Diet and Exercise

a, Typical dail) diet:
Yes l ) No l✓ )texplain)
b1 Able to conduct Activities of daily living (AOL)?
14) Personal Habits (Smoking, Alcohol)
I Smoki11e Alcoliol
a) ~e\.er smoked{__..,,,) quit smoking ( ): \\'hen: ► No use l ) Social use: 'week;
Quantity:
b)Ho~ long did they smoke? - - Years

c)Smokes packs day ).- Regular use: /week:

d) Exposure to second hand smoke

hours.day
-- ► Quantit):

Namt & Sip.?.')~dent

~m~~
 INTEGRAL UNIVER SITY
FACULTV OF PHARMACY
LUCKNOW

Medication History !ntervlew..lsllm

(Pharm.o. Internship)

l DemograP.hic 1md Social h1fo!:1!!_11t~n

Pat1e111 lPN07~53 Age /JOY

2) Chief Complaints

- Re.dne.gs and. 3we//,' '>Ji x 1-d~~

- lurnp on +he. hock x ::f-rl°rfi~

3) History of Present Illness: b K A /J cf,

o/},8 oc ,:,, en s e w_rv,
po-1-ieni:' r,,ru OffM1'111!f,,o;~lt 1-
deuelof Recfnegg ancl swel/ inb ()nrl, she o&o wmf /olJlls_
lu. m fJ on -fh e b ock Ph om 1- do)fJ ,
4) Past Medical History: SJ Past Surgical History:

No H/o - HTN; om ,Tif No H/o /Jv. '7Jlf_nd)

6) Past Medication History: 7) Family History:

Mtdicol-,'tm [SES
No 1-1 / o

8) Immunization History:
Date Last Received
Immunization Type

Influenza 7
Tetanus I /)()n~
BCG _J
Others:

9) Allergies (Medication and Food) /Adverse Reactions·

No. Product Name Type and Severity of Reaction

None
'i

'
 · t'10 11 /\1t-dk11lious
J> rr~ rnp oa, .
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lhu l! IJrarui \11111r I

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r-
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I t I
)
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me nts
< l/N utr itional products and sup ple t
iption Medications/Herba
Da, ;
11) C ur-ren t Non -Prescr Route of Fre q -i 5 I 61 - I
Dos e I 2 3
I Ind icat ion adm in
Dru g brand nam e Generic nam e

I
I - ,,, ' "

l I
"
Ass ess me nt of Ou tpa tien t Medication Complian ·ce
12) for this pat ien t?
medicatiofl administration
a) Who is responsible for
n ins tru ctio ns?
com ply ing wit h me dic atio
Do es pat ien t hav e any d(fficulty understanding or
b)

adherence? Ifyes explain:

c/ Barriers to medication

13) Die t and Ex erc ise

aJ Typical daily diet:
of daily living (AOL)? Yes ~ o ( ) (explain)
b) Able to conduct Activities
14) Personal Habits (Smoki
ng, Alcohol)
Alc oh ol
Smokin /week;
) quit smoking ( ): When: ► No use ( Social use:
a) Never smoked (
Quantity:
b)H ow Jong did they smoke
? Years

c)Smokes 4
packs/day ► Regular use: /week;

d) Exposure to second Jrnn

d smoke ► Quantity:
hours/day

Signa~
 INT EG RA L UN IVE RS ITY
FACULTY OF PHARMACY
LUCKNOW

Medic ation History lnter.Yle.Yt.f.Qrm

- !l_ Dt'mog1·!!.l!hic:.. _n_!td S~d 11l lnfonnn!ion

Patii:1~ l rN( ~~
6 ~~f'~!i-~ :l_(J .~N ttr,
(Pharm.n lntern'ihip)

_
c:cnd:r_fcmrr/(' l l lcigh t

J
- lw~ight s_0 :g - -J
[ R:ltµit'l1 /';/w:,/r m _l:rnpalion_, Prcg 11 a11I Y cs or ~() Hreast feeding. Ye, ;Jr N3-- - -

2) C' hief Com plai nts ----------

urpe't /lb rJomen X Q rnon!h.
- fM n rn
Bwm i'1$-., ftJ/t I wtt 'Ilon x 1,c(_ogl~
l eueQc ()n. (o ff 'I 3· l/ d!o t.J!.
i
. . C
.
3) His tory of Pre sent Illness:
r:eme D.)1'//i cli.w'1 cernr:lrrud$__ o/ _!he fClm t~ llf /J eJr. Ab d.f.ffnen , o/7or rt \
f.Olren{- »1ct-ifJrl a._nrl H.UVl.. f5n/t, Ff
imanlh cwc l s~e. a!J..D CJ)m;loml~ /JlL'rzn.tr1J_,Mr'e./1
Sin ce i,
CL(Jfl__.-5, .
m
5) Past Surgical History:
4) Past Medical History:
'
' No H/o Me.cf.e ·colt im i

No /Yler&caf 1-/t'slo't/
7) Family History:
6) Pas t Medication History:

No H/o rSlthJWjji No[, $.~nrl,ca11 !-

\

8) Immunization History: Dat e Las t Rec eive d

Immunization Type

Influenza 7
Teta nus J t; tJnt!!.
BCG
Others: rfJ91Anr,

9) AJler,gies (Medication and Foo

d) /Adverse Reactions:
\ Type and Severity of Reaction
No. Product Name

None

l
"
 ••
• I 0) < tllTl'III Prl'sniption l\11•clfr11tion,
- no,t' Rontr of Freq
Oavs I

• Dru~ Hrnnd Nnmr (,l'n<"rk NRml' lndk11linn \rhnin l 2 3 4 5 6 7

-- ...
·-•·-
. .,
lln.J Manact). ,_[rjl ?a01Jlllf' !lt,lt'li,a//r.,s l19m IV -,- ~
~ ,

•
8
IJ4Jl!!ii1 at.In.~ /k1ir1 ,yly,ros,
rJ_;.:µw!ap__ l'onln;mn2ole_ _
rfr. '" 011/ilio!t l'.3 t)tJ6.flfl6
'I flm.!j- _JjL
[\L_ e-8..li ~
[)11
,· \..
I•

,
I
v

'I fYHJ. IY Im -~· -~

Pa /tlf r.tJ lS.e f Gnrla.J rt1ton //J1Jrnl ~ t \i~ l]U:
,, -
--.""
1!f;- mfl.Dul- nJe.bto11adruok.. I I a f:., ~nn ✓
,
R
I]. ,1~111rxka.L Ls Dme.p?lil~lr..
·- U !al
fl
0
~

B0 " J v,
Al\
L..te;}Qi. !m_J~ ,__ll,il/W/JJ, -
I
- .Jlali
2) {) 0 fl
Z~ l.1~1-e lL )i1-lfll~Jl/)J{!e l ILL
r "" ,3o rn l 0 r-rn / ,, I I
; l
I rS11n fi,,f,).111 f~r I

I I
J' I
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11) Current Non -Prescription Medications/Herbal/Nutritional products and supplemen ts

"
fl' Drug brand name Generic name Indication Dose
Route of
admin
Freq l 2 3
Davs
4 5 6 -

""'
.....
12) Assessment of Outpatient Medication Complianc e
(" a) Who is responsible for medication administration for this patient?

b) Does patient have any difficulty understanding or complying with medication instn1ctions?

c) Barriers to medication adherence? Ifyes explain:

r
13) Diet and Exercise
a) Typical daily diet:
b) Able to conduct Activities of daily liv\ng (ADL)? Yes( ) No( )(explain)
14) Personal Habits (Smoking, Alcohol)
Smokine Alcohol I
a) Never smoked 4./1guit smoking ( ): When: )'
No use ( ---+Social use: /week;
Quantity:
b)How long did they smoke?
- - Years
c)Smokes packs/day
► Regular use: /week;
d) Exposure to second hand smoke
hours/day - ► Quantity:

\
Name & Sign. of Student
' , Signature of Preceptor
t ~
~/
 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW

Medic atJ.Q.o.li!Jt.9rv lntervtew...f.Qrm

(Pharm.D. Internship)

1 _ D_t'll10~E!!_i£_ ll_!!d Soci11l Info, m1tlitt!I

1Ocmkr / r:mn/r' J
3
l lc1ght W~1ght
:t=n~' ~o· ~£ ?J!/t!!l' ,?
1
> YM"l
Reltg1011 //tn'"J..ti Occupa1ion ff/ii• P1egm111t Yes m No Breast feechng. Y cs or l\lo

-- -
2) ChiefComplaints

I - ruf!orss c. flttadiA 1/bclomen X 'J rt~y,~

- - pMn in /oWt'.9t f/be0mNi ,x 15r{c/i~

3) History of P1·esent Illness:

pal-ienf- crme wi-lA c.AteA cemflatnf$,_ e} !he !idlnes~ fJj lhe 11 a'dt~tJ-i
Ln !lbriernen S tnce 5 d_aJM and slie. a//2{) complrunls___ ~ f 0.U) 1 n +lie.
L!Jt.,5€'Z. llbel£1tn en. Rrnm to cf o. .&
4) Past Medical History: 5) Past Surgical History:

r/o Medicaf l/tslc171, Nrme

6) Past Medication History: 7) Family History:

fl /s
8) Immunization History:
Date Last Received
Immunization Type
Influenza

Tetanus one
BCG

Others:

9) Allergies (Medication and Food) /Advers,e Reactions:

No. Product Name Type and Severity of Reaction

No
 ~ns
I 0) C urre nt ~r_es c-ript~o n ~Nl kntif Day,
I-lout.- of r•r.-q.
lnd fralio o J> o,e \, lm in
l>rui:? ll n 111d N om e ( il'lu-r k "ll n tn('

Ul/1C. '.L9rn . JV BD _ ,.,_,, ~

t'.~- - - · - 5 /}() 11) J " /

i/
'lorn7 i,, .

,, tn7
(J..Afri_L I
1 {_[j /}..
/
I
H
1

icati ons/ Her bal/ Nutr ition al prod ucts and supp leme nts
-
I J) Cur rent Non Pres crip tion Med Rout e of Freq
Davs
I 7
Dose l 2 3 4 5 6
Gene ric nam e Indic ation admi n I
Drug bran d nam e I

"';

·y ' ,, S;'
.,
/.,; .

on Compliance
12) Assessment of Outpatient Medicati
administration for this patient?
a) Who is responsible.for medication
on instr uctio ns?
rstanding or com plyin g with med icati
bJ Do es pati ent have any difficulty unde

Barr iers to med icati on adhe renc e? If

yes explain:
c)

13) Diet and Exercise

a) Typ ical daily diet:
livin g (AO L)? Yes ( ) No (\,---,(explain)
b) Abl e to cond uct Activities of daily
14) Personal Habits (Smoking, Akohol)
Smokin Alco hol
k;
a) Never smo ked quit smo king ( ): When: ► No use (.....-t'Social use: _ __ _/wee

b)How Jong did they smoke? __ Years

Quantity:
- -- -- ----
c)Smokes _ _ packs/day ► Regular use: _ _ ___;/week;

d) Exposure to second hand smoke ► Quantity:

-- -- -- -- --
.hours/day