Medication Review

MEDICATION REVIEW

Patient Name:______DOB:______Phone Number:______

Date of Service:______Primary MD: ______

MD Phone/Fax: ______

Other MDs:______

Allergies and Reaction / Immunizations (with date) / Cognitive Status
□ NKDA
□ Food Allergies / □ Influenza
□ Pneumococcal
□ Td/Tdap
□ Zostavax
□ Other:
□ Other: / Is the patient cognitively impaired?
□ YES □ NO
Is the Medication Review with the patient?
□ YES □ NO
If no, who is the recipient?
Name: Relationship:
Recipient Address:
Current Medical Conditions (include year of diagnosis)
□ Alzheimer's Disease
□ Anemia
□ Asthma
□ Autoimmune Disorders
□ BPH
□ Bipolar Disorder
□ Cancer (include type)
□ Chronic Lung Disorder / □ Chronic Pain
□ COPD
□ Depression
□ Diabetes
□ Dyslipidemia
□ GERD/Ulcer
□ Conditions Glaucoma
□ Heart Failure / □ Hepatitis C
□ HIV/AIDS
□ Hypertension
□ Menopause
□ Multiple Sclerosis
□ Neurologic Disorders
□ Osteoarthritis
□ Osteoporosis / □ Parkinson's Disease
□ Renal Insufficiency
□ Rheumatoid Arthritis
□ Schizophrenia
□ Stroke
□ Thyroid Disease
□ Post-MI
□ Post-TIA/Stroke
Physical Assessment / Pain / Blood Pressure
Height:
Weight:
BMI:
Goal BMI: / Scale:
1 2 3 4 5 6 7 8 9 10
Location:
Type: / 1.
2.
Avg:
HR: / At Goal?
□ YES
□ NO
Labs (complete only those pertinent to patient and include date obtained)
TC:
LDL:
HDL:
TG: / A1c:
FBG:
PPG: / AST/ALT:
TSH:
sCr:
CrCL:
BUN: / K:
Cl:
Na:
CO2:
PTT/INR: / FEV1:
PEF:
Other:
Prioritized Problem List
Problem / Related Drug Therapy Issue
(If applicable) / Reason * / Plan
1.
2.
3.
4.
5.
6.
7.
* Reasons for altering drug treatment regimen
Indication / Effectiveness
Unnecessary / Needs Additional / Needs Different Drug Product / Dosage Too Low
No medical indication / Needs additional therapy / More effective drug available / Wrong dose
Duplicate therapy / Untreated condition / Condition refractory to drug / Wrong frequency
Treating avoidable ADR / Preventative/prophylactic / Dosage form inappropriate / Drug interaction
Addictive/recreational / Synergistic / Not effective for condition / Drug inappropriate
Safety / Adherence
Adverse Drug Reaction / Dosage Too High / Noncompliance
Undesirable effect / Wrong dose / Directions not understood
Unsafe drug for patient / Wrong frequency / Patient prefers not to take
Not titrated properly / Duration inappropriate / Patient forgets to take
Allergic reaction / Drug interaction / Drug too expensive
Contraindication present / Incorrect administration / Cannot swallow/ administer
Additional monitoring needed to ensure safety / Incorrect administration technique
Patient Medication Record
Patient Name: ______DOB: ______
Primary MD: ______MD Phone/Fax: ______
Name and Strength / Directions / Condition / Special Instructions / Prescriber
OTC/Supplements/Herbals
Name and Strength / Instructions / Condition / Special Instructions
Medication Action Plan
Medication / Problem / What Patient Should Do