MHI_FORM

Department of Pharmacy Practice,

PATIENT MEDICATION HISTORY INTERVIEW

PATIENT DEMOGRAPHICS:

Name: _______________________Sex: M/F (Pregnancy status :____) Date of admission:___________ Patient consent

Hospital no: _____________ I.P. No.________________ Age: _______ Weight:_______ (Kg) Ht (m): __ BMI: ___

Ed. qualification: Illiterate Inter PUC UG PG Occupation: _____________Languages known/ conversant in:__________

CHIEF COMPLAINTS ON ADMISSION:

Medical history/ surgeries: Social history Duration Diet

Smoker(pack/years)

Alcoholic

Tobacco chewing

Snuff

Others

No habits

Analgesics Ant-acids OCP’s Cough syrups Nutritional Supplements/ Vitamins

Herbal supplements

Topical medication

Vaccination status

Alternate system of medicine

Ayurveda Homeopathy Unani Siddha

RECENT HOSPITALIZATION: Yes No

No. Of hospitalizations in the past month:

Reasons for these hospitalizations:

Duration of most recent hospitalization:

MEDICATION HISTORY CHART FOR PRESCRIPTION MEDICATIONS

Date Medication and Frequency with Strength Indication Duration Last dose taken on:

Any drug related problems/ADR/ ADE

Date Medication and Frequency with Strength Indication Duration Last dose taken on:

Any drug related problems/ADR/ ADE

DOCUMENTED DRUG ALLERGIES

Drug Date of allergy

Brief description of the allergy

Data sources referred to:

Patient Patient party Prescriptions Patient’s medication

Case file Discharge summary

REASONS FOR NOT INTERVIEWING THE PATIENT:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________

ASSESSMENT OF COMPLIANCE BEHAVIOUR

Interviewer’s Signature with date