STUDENT NAME:

STUDENT #:

DEMOGRAPHICS

CONTACT INFORMATION

Pharmacotherapy Workup NOTES

Name
Address

Telephone (h)

Physician

ASSESSMENT
City

(w)

Province

e-mail

(cell)

(address)

(tel)

(fax)

Specialist

(address)

(tel)

(fax)

Postal Code

Age

Date of Birth (D/M/Y)

Weight

Height

Ethnicity

Due Date/Trimester

Breast Feeding No

Pregnancy status No
Occupation

Living Arrangements/Family

Personal Health Number

REASON FOR ENCOUNTER

Gender Unknown

Third Party Plan

What is the patients general attitude toward taking medication?

Needs
attention in
care plan

What does the patient want/expect from his/her drug therapy?

Needs
attention in
care plan

What concerns does the patient have with his/her medications?

Needs
attention in
care plan

To what extent does the patient understand his/her medications?

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

Describe the patients medication taking behaviour

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

Current on all childhood immunizations

SOCIAL DRUG USE

SUBSTANCE

HISTORY

OF

USE

SUBSTANCE

0-1 packs per day

Tobacco
No tobacco use

>1 packs per day

previous history of
smoking
attempts to quit
2-6 cups per day
> 6 cups per day

No caffeine use

OF

USE

< 2 drinks per week

Alcohol

2-6 drinks per week

> 6 drinks per week

No alcohol use

history of alcohol
dependence

< 2 cups per day

Caffeine

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

ALLERGIES & ALERTS

MEDICATIONSCURRENT MEDICAL CONDITIONS AND

Adverse reactions to drugs in the past

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

PAST DRUG THERAPIES

*stable, improved, partially improved, worsened, resolved, failed

MEDICAL
RESPONSE*
DRUG THERAPY
EFFECTIVENESS/SAFETY
CONDITION

DATE

*stable, improved, partially improved, worsened, resolved, failed

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

PAST MEDICAL HISTORY

(RELEVANT ILLNESSES, HOSPITALIZATIONS, SURGICAL PROCEDURES, INJURIES, PREGNANCIES)

RELEVANT FAMILY HISTORY

(E.G. GENETICALLY ASSOCIATED CONDITIONS)

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

DRUG THERAPY PROBLEMS

MEDICAL CONDITION
(PROVIDE

TO BE

AND

RESOLVED

MEDICATION(S) INVOLVED

RATIONALE FOR

DTP

SELECTION)

NECESSARY
Unnecessary Drug Therapy

(e.g. no medical indication,

addictive/recreational, nondrug
therapy indicated, duplicate
therapy, treating avoidable ADR)
Needs Additional Drug Therapy
(e.g. untreated condition,
synergistic/potentiating,
preventive/prophylactic)

MEDICAL CONDITION
(PROVIDE

AND

MEDICATION(S) INVOLVED

RATIONALE FOR

DTP

SELECTION)

Ineffective Drug

DRUG THERAPY PROBLEMS

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)

Dosage Too High

(e.g. dose too high, frequency too
short, duration too long, drug
interaction)
Adverse Drug Reaction
(e.g. unsafe drug for patient,
allergic reaction, incorrect
administration, drug interaction,
dosage increase/decrease too fast,
undesirable effect, contraindications
present)

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)

No Drug Therapy Problems at this time

Signature:
Date:

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

List deviation from normal (and relevant baseline values)

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

REVIEW OF SYSTEMS - continued

Signs,
Symptoms
Lab value
Date

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

List deviation from normal (and relevant baseline values)

Adapted with Permission: St.Paul's Hospital Pharmacy, Providence Health Care, Vancouver 2004

Phar Handbook
Copyright 2012 UBC Faculty of Pharmaceutical Sciences