1 2 3 4 5 6 - Yale School of Medicine
SUNDAY |MONDAY |TUESDAY |WEDNESDAY |THURSDAY |FRIDAY |SATURDAY |Patient ID: ____________________
1. How many times a day do you take prescription medications, including pills, inhalers, drops, liquids on a regular basis?
No meds
1
2
3
4
5
6
7
8
2. How many medications do you take at each of these times?
Time of
day
# of
Meds
Changed?
T1
T2
T3
T4
T5
T6
T7
T8
Total
3. Did anything cause you problems or difficulties in taking your medications?
No
Yes, _________________________
| |
Late Missed |
Late Missed |
Late Missed |
Late Missed |
Late Missed |
Late Missed |
Late Missed |Date: ___________________________
1. In the past 30 days, has there been a change in the number of prescription medications or doses of a particular medication that you have been taking?
NO (0) YES (1)
2. How many times a day do you take prescription medications, including pills, inhalers, drops, patches, injections or liquids on a regular basis?
0 1 2 3 4 5 6
3. How many medications do you take at
each of these times?
Association
1 = get in/out of bed 4 = work
2 = meal 5 = other
3 = regular interval (specify)
Time of
day
Association?
#
T1
T2
T3
T4
T5
T6
Total
4. Are there side effects from any of your
medications that cause you to either miss a dose or take it late?
No
Yes, _________________________
_____________________________
5. Do you use anything or anyone to help you take your medications?
0 = nothing
1 = pill box
2 = alarm / beeper
3 = checklist / log
4 = household member
5 = DOT (professional)
6 = other _______________________
| |
| T1 | T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | |
| T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | |
| T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | |
| T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | |
| T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | |
| T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | |
| T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | |
| T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | |
| T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | |
| T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | |
| T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | |
| T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | |
| T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | |
| T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | |
| T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | |
| T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | |
| T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | T 1 | |
| T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | T 2 | |
| T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | T 4 | |
T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | T 6 | | |
| | | | | | | | |
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