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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