8/17/2019 Medication History Checklist

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Medication History Checklist

Check YES NO

Allergies

List medication/ food aller gies

Adverse Effects

List adverse effects as described by patientList abnormal laboratory findings

List documented adverse effects

Current Medications

List current medications

Indication, dosage, schedule, duration, outcome

Quantify use of P! medication

Past Medications

List past medications

Indication, dosage, schedule, duration, outcome

"hy #as drug discontinued$

Non-prescription Medications

%&C, C'Ms, vitamins, minerals, other supplements

Other Medications & Iuni!ations

Medication samples

Immuni(ation History

Medication E"perience

Individual)s sub*ective e+perience of taking a medication

Medication Adherence

Ho# medication prescribed vs ho# actually taken$

Ho# often in a #eek does patient miss a dose of medication$

"hat is the system used to manage/remember medication$easons for nonadherence

Other Medication Considerations

Concerns #ith cost of medication