Section C Medication History
We are interested in the medicines your doctor may have prescribed to help your lupus.
Please answer as completely as you can, but we know it may be difficult to remember some of these details.
EXAMPLE: If you are on Prednisone and Plaquenil, you would answer as follows:
IF YES:C1.
Have you taken any of the following prescription medications? / C2.
In what year did you start taking this drug? / C3.
If you have ever taken this drug,
have you taken it in the past 4 weeks? / C4.
What is your average daily dose in the
past 4 weeks?
a. Prednisone / ☒1 Yes □2 No / 1996 / ☒1 Yes □2 No / 15 mg once a day
b. PlaquenilR (hydroxychloroquine) / ☒1 Yes □2 No / 2003 / ☒1 Yes □2 No / 200 mg twice a day
e. Methotrexate / □1 Yes ☒2 No / ______/ □1 Yes □2 No / ______
The following 2 pages ask about lupus medications, pain medications, and medications for blood pressure, cholesterol, and other medical conditions.
Section C – Medication History (Lupus Drugs)IF YES: / IF YES:
C1.
Have you ever taken any of the following prescription medications? / C2.
In what year did you start taking this drug? / C3.
If you have ever taken this drug,
have you taken it in the past 4 weeks? / C4.
What is your average daily dose in the
past 4 weeks?
a. Prednisone / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
b. PlaquenilR (hydroxychloroquine) / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
c. Aralen R
(chloroquine phosphate) / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
d. ImuranR
(azathioprine) / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
e. Methotrexate / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
f. Cyclophosphamide / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
g. CellceptR
(mycophenolate mofetil) / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
h. AravaR
(leflunomide) / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
i. Cyclosporin / □1 Yes / □2 No / ______/ □1 Yes / □2 No / ______
j. Coumadin / □1 Yes / □2 No / ______/ □1 Yes / □2 No
k. Low dose “baby” aspirin (daily) / □1 Yes / □2 No / ______/ □1 Yes / □2 No
l. Cox-2 inhibitor (Celebrex, Bextra, Vioxx, Mobicox) / □1 Yes / □2 No / ______/ □1 Yes / □2 No
m. NSAID (non-steroidal anti-inflammatory, e.g. naproxen, Voltaren, Arthrotec, keoprofen, etc.) / □1 Yes / □2 No / ______/ □1 Yes / □2 No
Section C – Medication History (Pain Medications)
If YES:
C5. Have you taken any of the following drugs in the last 4 weeks? / C6. How often did you take this medicine, in the past 4 weeks?
a. Ibuprofen, Motrin, Advil, Nuprin, or Medipren / □2 No / □1 Yes / □1 less than once a week
□2 about one day a week
□3 2 or more days a week
b. Acetaminophen or Tylenol / □2 No / □1 Yes / □1 less than once a week
□2 about one day a week
□3 2 or more days a week
c. Aspirin, Anacin, Bufferin, Bayer, Excedrin, or Ecotrin / □2 No / □1 Yes / □1 less than once a week
□2 about one day a week
□3 2 or more days a week
d. Naproxen or Aleve / □2 No / □1 Yes / □1 less than once a week
□2 about one day a week
□3 2 or more days a week
Section C – Medication History (Other Conditions)
If YES:
C7. Have you ever taken any prescription medications for the following conditions? / C8. Have you used this medication in the
past 4 weeks?
a. high blood pressure / □2 No / □1 Yes / □1 Yes / □2 No
b. high cholesterol / □2 No / □1 Yes / □1 Yes / □2 No
c. asthma / breathing problems / □2 No / □1 Yes / □1 Yes / □2 No
d. nerves, anxiety, depression, to help sleep / □2 No / □1 Yes / □1 Yes / □2 No
e. stomach problems / □2 No / □1 Yes / □1 Yes / □2 No
f. thyroid problems / □2 No / □1 Yes / □1 Yes / □2 No
g. seizures / □2 No / □1 Yes / □1 Yes / □2 No
h. bone density or strength, osteoporosis (Fosamax, alendronate, Actonel, risedronate, Didrocal) / □2 No / □1 Yes / □1 Yes / □2 No
For Women Only:
j. birth control pills or other hormonal contraceptive / □2 No / □1 Yes / □1 Yes / □2 No
k. hormone replacement or estrogen replacement for menopause / □2 No / □1 Yes / □1 Yes / □2 No
1000_Faces_Medication_PT_Nov05