Best Possible Medication History form



BEST POSSIBLE MEDICATION HISTORY (BPMH)—Patient Section

|PATIENT |

|First Name: | |PHN: | |Gender: | |

|Last Name: | |Date of Birth: | |Phone #: | |

|FAMILY PHYSICIAN |

|Full Name: | |Phone #: | |Fax # (if known): | |

|KNOWN ALLERGIES AND REACTIONS (if applicable) - Pharmacist: PLEASE PRINT |

| |

|MEDICATIONS I TAKE—Prescription, non-prescription, natural health products - Pharmacist: PLEASE PRINT |

|Patient is not taking any non-prescription or natural health products at this time. ( (Check box or give product details below) |

| |WHAT I TAKE |WHY I TAKE IT |HOW I TAKE IT |SPECIAL INSTRUCTIONS |

| |Name, strength & form of medication as noted |Disease, condition or symptoms it|For example, when to take it, take|(if applicable) |

| |on the prescription or medication package |addresses |with/without food, warnings, etc. | |

| |label | | | |

|1 | | | | |

|2 | | | | |

|3 | | | | |

|4 | | | | |

|5 | | | | |

|6 | | | | |

|7 | | | | |

|8 | | | | |

|PATIENT ACKNOWLEDGEMENT |

|My pharmacist has explained to me the purpose of a medication review service. I agreed that I could benefit from this publicly funded service. The review was conducted |

|in a place that respected my privacy. During the appointment my pharmacist fully explained any medication changes or concerns to me. At the end of the medication review|

|appointment, my pharmacist gave me a list of my current medications. The list includes any changes resulting from the medication review service provided.    |

|Signature of patient (or patient’s legal representative) |Date |

BEST POSSIBLE MEDICATION HISTORY (BPMH)—Health Care Professionals Section

|CLINICAL NEED FOR SERVICE |

|Prescriber: | requested a medication review | |

|Patient: (check one or more) | | |

|has multiple diseases |has a medication regimen that includes one or more |Or, for an MR-F (Follow-up), follow-up is: (Check one) |

|has one or more chronic diseases |natural health products |due to a subsequent medication change (i.e, a change in a |

|has a medication regimen that includes |has a drug therapy problem |medication entered on PharmaNet), or |

|one or more non-prescription |has been recently discharged from hospital |to implement and /or evaluate patient’s response to the |

|medications |has multiple prescribers |action taken to resolve a DTP. |

| |takes medication(s) that require laboratory monitoring | |

|CURRENT MEDICATIONS |

| |NAME OF DRUG & STRENGTH |PRESCRIBER NAME & PROFESSION |VERIFIED |ACTION |NOTES |

| | |For example, physician/MD, RPN, |Continue as per 1 = PHARMANET, |For example: Drug Therapy Problem|(if applicable) |

| | |naturopath, pharmacist, patient |2 = PATIENT (different than |plan, referral, follow up | |

| | | |PharmaNet), or 3 = PATIENT (not in|required | |

| | | |PharmaNet). | | |

|2 | | | | | |

|3 | | | | | |

|4 | | | | | |

|5 | | | | | |

|6 | | | | | |

|7 | | | | | |

|8 | | | | | |

|CLINICALLY RELEVANT MEDICATIONS THE PATIENT IS NO LONGER TAKING (if applicable) |

|NAME & STRENGTH OF DRUG |WHY IT WAS TAKEN |MOST RECENT REGIMEN |WHO STOPPED IT |COMMENTS |

| | | |Name of prescriber, pharmacist, other |Reason for stopping, effectiveness, other |

| | | |or patient |relevant information |

| | | | | |

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