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STUDENT #:
DEMOGRAPHICS
CONTACT INFORMATION
Telephone (h)
Physician
ASSESSMENT
City
(w)
Province
(cell)
(address)
(tel)
(fax)
Specialist
(address)
(tel)
(fax)
Postal Code
Age
Weight
Height
Ethnicity
Due Date/Trimester
Breast Feeding No
Pregnancy status No
Occupation
Living Arrangements/Family
Gender Unknown
Needs
attention in
care plan
Needs
attention in
care plan
Needs
attention in
care plan
Needs
attention in
care plan
MEDICATION* EXPERIENCE
No
No
No
No
Are there cultural, religious, or ethical issues that influence the patients willingness to take Needs
attention in
medications?
care plan
No
Needs
attention in
care plan
No
Medication*= drug includes: prescription, non-prescription, and natural health products
Adapted with permission from: 2009 Copyright Medication Management Canada and 2003-2005 Peters Institute of Pharmaceutical Care, Cipolle RJ, Strand LM,
Morley PC Pharmaceutical Care Practice: The Clinicians Guide, McGraw Hill, 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
IMMUNIZATIONS
SUBSTANCE
HISTORY
OF
USE
SUBSTANCE
No caffeine use
OF
USE
No alcohol use
history of alcohol
dependence
HISTORY
Other recreational
drug use:
history of caffeine
dependence
Medication Allergies (drug, timing, reactione.g., rash, swelling, shortness of breath, anaphylaxis)
Adapted with permission from: 2009 Copyright Medication Management Canada and 2003-2005 Peters Institute of Pharmaceutical Care, Cipolle RJ, Strand LM,
Morley PC Pharmaceutical Care Practice: The Clinicians Guide, McGraw Hill, 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
Other Alerts/Preferences/Health Aids/Special Needs (e.g., sight, hearing, mobility, literacy, disability)
MEDICAL CONDITION
MEDICATION
DOSAGE REGIMEN
DOSE, ROUTE, FREQUENCY,
DURATION
START DATE
RESPONSE*
EFFECTIVENESS
, SAFETY
DATE
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
NUTRITIONAL STATUS
OR
DIETARY RESTRICTIONS/NEEDS/EXERCISE
Adapted with permission from: 2009 Copyright Medication Management Canada and 2003-2005 Peters Institute of Pharmaceutical Care, Cipolle RJ, Strand LM,
Morley PC Pharmaceutical Care Practice: The Clinicians Guide, McGraw Hill, 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
Adapted with permission from: 2009 Copyright Medication Management Canada and 2003-2005 Peters Institute of Pharmaceutical Care, Cipolle RJ, Strand LM,
Morley PC Pharmaceutical Care Practice: The Clinicians Guide, McGraw Hill, 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
TO BE
AND
RESOLVED
MEDICATION(S) INVOLVED
RATIONALE FOR
DTP
SELECTION)
NECESSARY
Unnecessary Drug Therapy
MEDICAL CONDITION
(PROVIDE
AND
MEDICATION(S) INVOLVED
RATIONALE FOR
DTP
SELECTION)
Ineffective Drug
EFFECTIVENESS
(e.g. dosage form inappropriate,
condition refractory to drug, not
effective for condition, more
effective drug available)
Dosage Too Low
(e.g. ineffective dose, frequency too
long, duration too short, incorrect
storage, incorrect administration,
drug interaction)
MEDICAL CONDITION
(PROVIDE
AND
MEDICATION(S) INVOLVED
RATIONALE FOR
DTP
SAFETY
SELECTION)
MEDICAL CONDITION
(PROVIDE
AND
MEDICATION(S) INVOLVED
RATIONALE FOR
DTP
SELECTION)
ADHERENCE
Non-adherence
(e.g. drug product not available,
cannot afford drug product, cannot
swallow/administer, directions not
understood, patient prefers not to
take, patient forgets to take)
REVIEW OF SYSTEMS:
Signs,
Symptoms, Lab
value
Date
If abnormal, can it be
caused by patients
medications?
VITAL SIGNS:
Temp
BP
HR
RR
CNS /
NEUROLOGIC
Confusion
Drowsiness
Dizziness
Fatigue
Numbness
Tingling
EENT
Voice change
Swallowing
problem
Taste change
CVD
T. cholesterol
LDL / HDL
CO
SOB
Edema
Palpitation
PULMONARY
SOB
Wheezing
Coughing
Phlegm/Blood
Peak Flow
FLUID &
ELECTROLYTE
Na+
K+
Ca
ClHCO3
Mg2+
Adapted with Permission: St.Paul's Hospital Pharmacy, Providence Health Care, Vancouver 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences
If abnormal, can it be
caused by patients
medications?
RENAL
Se. Cr.
CrCl
LIVER
AST
ALT
Albumin
Bruising
Bleeding
DERMATOLOG
Y
HEMATOLOGY
Hgb
Platelets
WBC
Neutrophils
INR
PTT
DRUG LEVELS
Digoxin
Theophylline
Lithium
CULTURES
GI
GU /
Reproduction
ENDOCRINE
Se. Glucose
HgA1C
TSH
T4
MSK
Adapted with Permission: St.Paul's Hospital Pharmacy, Providence Health Care, Vancouver 2004
Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences