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Medication History Worksheet Patient Name: _______________________________________ DOB____________________ GENDER__________ MRN ___________ Height: _________ Weight: ___________ HR: _________ BP: ____________________ Mailing Address: _________________________________________________________________________________ Home Phone: _____________________________________ Work Phone: __________________________________ Prescription Insurance or Payment Method: __________________________________________________________ Pharmacy Used: __________________________________________________________________________________ Medical History (Indicate year of diagnosis or years diagnosed): ________ Hypertension ________ Diabetes ________ Hyperlipidemia ________ CAD ________ Asthma ________ COPD ________ Osteoporosis ________ GERD ________ Depression ________ Anxiety ________ Hyperthyroidism ________ Hypothyroidism ________ Osteoarthritis ________ Other _______________________________________________________________ MEDICATION ALLERGIES AND INTOLERANCES Agent Reaction Pacific University School of Pharmacy PHARM 641 Date Occurred Medication History Worksheet PRESCRIPTION MEDICATIONS Medication Start Date DC DATE Generic Name (with brand in parenthesis if used by patient) dd/mm/yyyy dd/mm/yyyy Strength Stated Purpose SIG Qty Route Frequency Pacific University School of Pharmacy PHARM 641 Comment Prescribed By Medication History Worksheet NONPRESCRIPTION MEDICATIONS Start Medication DC DATE Date Generic Name (with brand in dd/mm/yyyy dd/mm/yyyy parenthesis if used by patient) Strength SIG Qty Route Stated Purpose Frequency Pacific University School of Pharmacy PHARM 641 Comment Medication History Worksheet : SOCIAL SUBSTANCES Type Substance Current Use and Frequency History of use Caffeine Tobacco Alcohol Illicit Substances IMMUNIZATION STATUS DATE LAST RECEIVED INFLUENZA PNEUMOCOCCAL TETANUS CIRCLE IF APPLIES Unknown OR Never Unknown OR Never Unknown OR Never NOTES:__________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Pacific University School of Pharmacy PHARM 641
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