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Appendice A - Medication Review Forms What is a Medication Review? A Medication Review is a service that involves your pharmacist performing a complete assessment of your medications What benefits are there from having a Medication Review? Address any questions or concerns that you have about your medicine Ensure that you are receiving the best medicine therapy possible Increase your knowledge about your medicine Increase your confidence in using your medicine Reduce your risk of problems from your medicine Are you taking several medications Do you ever have trouble using your (including natural products and non- medicines (swallowing, puffers, eye prescription products) drops, patches) Do you have more than one doctor or other health care provider Do any of your medications make you feel unwell Does the cost of your medicine make it hard for you to take it as prescribed Do you have trouble understanding or remembering how to take your medicine Do you feel that you are taking too many medicines Do you worry that your medicines are working against each other Have you recently been discharged from the hospital Do you wish you knew more about your medicine Pharmacy Contact Information Here Patient Name: PHIN: DOB: Pharmacist: Phone: Best Possible Medication History 1. Patient Information Name Gender q Male Age Third Party Coverage Family Physician qFemale Address Postal Code Reason for Med Review qUndifferentiated City/Province Phone # Other Physician/Specialist Caregiver (if applicable) Phone # Pharmacist Completing Review License No. What is your primary concern about your medications today? What are your expectations from your medications, and what would like to achieve from your med review today? 2. Consent q I have received information on, and have consented to review process Patient Signature:_ q I have agreed that information may be shared with my physician and other healthcare providers Patient Signature:_ q I consent to having my patient representative/caregiver involved in medication review (if applicable) Name of Representative(s):_ Patient Signature: Clear selection Pharmacy Contact Information Here Patient Name: PHIN: DOB: Pharmacist: Phone: 3. Health Information and Lifestyle Factors Inquiry Yes/No Details/Comments a. Allergies qY qN Reaction: b. Smoker c. Alcohol Consumption qY qN qFormer Smoker qY qN Cigarettes/day: X years Drinks/week: d. Caffeine Intake qY qN Cups/day: e. Grapefruit (Juice) Consumption qY qN Comments: f. qY qN qRestricted Diet qY qN Type of activity: Is now a good time to quit? Nutritious Diet g. Physically Active Minutes/week: h. Recreational/Other Drug Use qY qN i. Yearly Influenza Immunization qY qN j. Pneumococcal Immunization (if ver 65) k. Other Vaccinations (travel, routine, etc.) l. Screening Completed (breast, colon, cervical, etc.) m. Eye Exam, Hearing test within last year qY qN n. Regular or recent lab tests qY qN Date/Result: Height: p. Do you live alone? qNormal qOverweight qUnderweight qY qN q. Aids, Alerts, Devices, etc. Other qY qN Please list: qY qN What/When: qY qN (copy & attach results if possible) o. Body Mass Index (BMI) Weight: Clear selection Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ 4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters) Kidney Disease? CrCl = Liver Disease? BP = HR = RR = Y N NA Pregnant? Trimester: Y N NA Breastfeeding? E.g. Diabetes Type II, diagnosed in ___ HgA1C = 7.2% (mm/yyyy) Tests 3 times daily (blood glucose diary copied and attached), sees foot specialist on regular basis 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Head to toe Assessment regarding other complaints/concerns/bothersome symptoms: Complaints/Concerns: Bothersome symptoms: Do any ever require self treatment? Family History Clear selection Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ 5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies) Medication Name, Strength How Taken Dose, Route, Frequency, Time of Day, Special Instructions Purpose for Use How long taken Issues Identified Yes: Proceed to DTPs Identified No: Verify to continue as per Additional Comments Clear Selection Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ 6. Recently Discontinued Medications Medication Name, Strength How Taken Dose, Frequency, Time of Day, Special Instructions Purpose for Use How long taken? When was stopped? Who stopped it? Reason for Stopping? Require Further Action? Yes: Proceed to DTPs Identified No: Verify to continue as per Clear selection Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ Drug Therapy Problems Identified No drug therapy problems were identified Priority Number Drug Therapy Problem (DTP) _____ _________________________________________________________________ _____ __________________________________________________________________ _____ __________________________________________________________________ _____ __________________________________________________________________ _____ __________________________________________________________________ _____ __________________________________________________________________ For those drug therapy problems above which can be corrected with immediate action and no further research or consultation, document your plan below: DTP # Proposed solution Discussed with patient Follow-up Plan For those drug therapy problems requiring further research, contact with other health care providers and care plan development, utilize the Pharmacy Care Plan worksheet. ____________________________________ Pharmacist signature __________________________ Date of Review Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ Pharmacy Care Plan Data: Subjective information provided by the patient and/or objective data that you have collected. Assessment: State the drug therapy problem. Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug coverage and non-pharmacological interventions. Alternative #1: Alternative #2: Monitoring: Planned date of follow-up: ____________________________ ____________________________________ __________________________ Pharmacist signature Date of Review Pharmacy Contact Information Here Patient Name: PHIN: DOB: Phone: Pharmacist: _____________________ Patient Action Plan Date of Comprehensive Medication Review: _________________________ As a result of my comprehensive medication review, I will do the following: 1. 2. 3. 4. 5. 6. 7. Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association. (2010). Program Guidance Document, NB Pharmacheck. Pharmacy Contact Information Here Patient Name: PHIN: DOB: Pharmacist: Phone: Patient Follow-‐Record Date of Follow-‐Up Reason for Follow-‐up Results Pharmacist Comments & Plan Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Clear selection Health Care Practitioner Communication Form Date:_______________________ Health Care Practitioner Re: (Patient’s Name) Address Address Phone # Fax # DOB PHIN Phone # Pharmacy Contact Information Here Pharmacist: _____________________ Dear Dr._____________________, Your patient had a Comprehensive Medication Review completed on ________________. Listed below are my assessment(s) and recommendation(s). Please provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me. Drug Therapy Problem Pharmacist Recommendation Information Only Information Only Pharmacist Name: License #: Make Changes as Recommended Prescriber Comments/Revisions Action Required Yes No Yes No Action Required Prescriber Signature: License #: Date: THIS TELECOPY IS CONFIDENTIAL AND IS INTENDED TO BE RECEIVED BY THE ADDRESSEE ONLY. IF THE READER IS NOT THE INTENDED RECIPIENT THEREOF, YOU ARE ADVISED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS FACSIMILE IS STRICTLY PROHIBTED. USE OF THIS FORM FOR PURPOSES OR BY PERSONS, NOT AUTHORIZED UNDER THE CONTROLLED DRUGS AND SUBSTANCES ACT AND ITS REGULATIONS IS A CRIMINAL ACT. PRACTITIONER CERTIFICATION: THIS PRESCRIPTION REPRESENTS THE ORIGINAL OF THE PRESCRIPTION DRUG ORDER, THE PHARMACY ADDRESSEE NOTED ABOVE IS THE ONLY INTENDED RECIPIENT AND THERE ARE NO OTHERS, THE ORIGINAL PRESCRIPTION HAS BEEN INVALIDATED AND SECURELY FILED AND IT WILL NOT BE TRANSMITTED ELSEWHERE AT ANOTHER TIME, QUANTITY MUST BE STATED IN WORDS AND NUMERALS Form adapted from: The Ontario Pharmacists Association, MedsCheck. Clear selection