Case:
A. Patient Description
Name: Age:
Reg. No: Gender: Male [ ] Female [ ] Admission:
Weight: kg Race:
B. Chief/present Complaint (CC)
C. History of present illness (HPI)
D. Family & Social History
E. Medical History Interview:
HEART PROBLEMS:
Chest pain (angina)
Past heart attack
Heart Failure
Irregular heartbeat
Heart by-pass surgery
URINARY/REPRODUCTIVE:
Urinary or bladder infection
Chronic Yeast Infection
Kidney disease
Dialysis
Other:
EYES, EARS, NOSE & THROAT MUSCLES AND BONES
Poor vision Arthritis
Poor hearing Gout
Glaucoma Back pain
Sinus problem Amputation
Other Joint replacement
GASTROINTESTINAL
Heartburn
Ulcer
Constipation
Liver disease
Pancreatitis
Gallbladder problems
NEUROLOGICAL
Headache
Seizures or epilepsy
Parkinson’s disease
Fainting
Depression
Anxiety
DO YOU HAVE? LUNG PROBLEMS
High blood pressure Asthma
Low blood pressure Bronchitis
High cholesterol Other
Diabetes DO YOU HAVE OR USE…?
Anemia Glasses
Bleeding disorder Hearing Aid
sleeping problems Other:
Hay fever
DO YOU HAVE A FAMILY HISTORY OF:
High blood pressure Diabetes
Heart disease Others:
F. Medication history
Current Prescription Medications
Medicine Name Frequency Dose/strength Indication
Prescribe BNF Prescribed BNF
d
Current Nonprescription Medication (OTC, herbal, homeopathic, nutritional, etc)
Drug Interactions
Drug Interact Cause/ Effect
G. Allergies:
History of allergies: Yes [ ] No [ ]
Are you allergic to any prescription drugs, over-the-counter medication, herbals or food
supplements?
Are there any medications that you are not allergic but cannot tolerate?
Environmental allergies
H. Medication Compliance assessment
How often would you estimate that you miss a dose?
______________________________________________________________________
What are the problems you are having with your regimen?
______________________________________________________________________
Compliance rate: Compliant [ ] Moderate/partial compliant [ ] Noncompliant [ ]
I. Social History ([Link])
Smoking: Yes No Not known
Alcohol: Yes No Not known
Drug/substance abused: Never consumed [ ], If yes What type _________________
Diet Routine:
Routine Exercise/Recreation
J. Physical examination / laboratory for initial and follow
Lab Investigation:
Weight:
BP(mmHg)
WBC:
HgB:
Platelet:
RBC :
LDL:
HDL:
Tot. Cholestrol:
OTHER:
Pharmacologic review of system:
General: __________________________________
HEPATIC: ___________________________________ CVS:
_____________________________________ CHEST:
_____________________________________
BLOOD: _____________________________________
ABDO: ______________________________________
SKIN/MUSCLE: __________________________________
NEURO/MENTAL: _________________________________
GIT: _________________________________________
Vital Signs
T (oC) _____________________________________
BP (mmHg) _____________________________________
HR (beat/min) _____________________________________
I/O: Input/Output (resp. rate) _________________________
K. SUMMARY AND COMMUNICATION
L. Pharmaceutical care recommendation