Appendice A - Medication Review Forms

What is a Medication Review?

 A Medication Review is a service

that involves your pharmacist
performing a complete assessment
of your medications
What benefits are there from having a
Medication Review?

 Address any questions or concerns

that you have about your medicine
 Ensure that you are receiving the
best medicine therapy possible
 Increase your knowledge about
your medicine
 Increase your confidence in using
your medicine
 Reduce your risk of problems from
your medicine
 Are you taking several medications
(including natural products and non-
prescription products)
 Do you have more than one doctor
or other health care provider
 Do any of your medications make
you feel unwell
 Does the cost of your medicine
make it hard for you to take it as
prescribed
 Do you have trouble understanding
or remembering how to take your
medicine
 Do you ever have trouble using your
medicines (swallowing, puffers, eye
drops, patches)
 Do you feel that you are taking too
many medicines
 Do you worry that your medicines
are working against each other
 Have you recently been discharged
from the hospital
 Do you wish you knew more about
your medicine
 Pharmacy
 Contact
 Information
 Here
 

Patient  Name:  
PHIN:   Pharmacist:  
DOB:   Phone:  

Best  Possible  Medication  History  

1. Patient  Information

Name   Age   Third  Party  Coverage  

Gender     Family  Physician  

q Male   qFemale   qUndifferentiated  

Address   City/Province   Other  Physician/Specialist  

Postal  Code   Phone  #   Caregiver  (if applicable)   Phone  #  

Reason  for  Med  Review   Pharmacist  Completing  Review   License  No.  

What  is  your  primary  concern  about  your  medications  today?  

What  are  your  expectations  from  your  medications,  and  what  would  like  to  achieve  from  your  med  
review  today?  

2. Consent

q I  have  received  information  on,  and  have  consented  to  review  process  

Patient  Signature:_    
q I  have  agreed  that  information  may  be  shared  with  my  physician  and  other  healthcare  
providers  
Patient  Signature:_  

q I  consent  to  having  my  patient  representative/caregiver  involved  in  medication  review  
(if applicable)  
Name  of  Representative(s):_  
Patient  Signature:    

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 Pharmacy  Contact  Information  Here  

Patient  Name:  
PHIN:   Pharmacist:  
DOB:   Phone:  

3. Health  Information  and  Lifestyle  Factors

Inquiry   Yes/No   Details/Comments  
a. Allergies qY     qN   Reaction:  

b. Smoker qY     qN   Cigarettes/day:  

Is now a good time to quit? qFormer  Smoker   X     years  
c. Alcohol  Consumption qY     qN   Drinks/week:  

d. Caffeine  Intake qY     qN   Cups/day:  

e. Grapefruit  (Juice)  Consumption qY     qN   Comments:

f. Nutritious  Diet qY     qN  

qRestricted  Diet  
g. Physically  Active qY     qN   Type  of  activity:  

Minutes/week:  

h. Recreational/Other  Drug  Use qY     qN  

i. Yearly  Influenza  Immunization qY     qN  

j. Pneumococcal  Immunization qY     qN  

(if ver 65)  
k. Other  Vaccinations qY     qN   Please  list:  
(travel,  routine,  etc.)
l. Screening  Completed qY     qN   What/When:  
(breast,  colon,  cervical,  etc.)
m. Eye  Exam,  Hearing  test  within qY     qN  
last  year

n. Regular  or  recent  lab  tests qY     qN   Date/Result:  

(copy  &  attach  results  if  possible)
o. Body  Mass  Index  (BMI) qNormal   Height:   Weight:  
qOverweight  
qUnderweight  
p. Do  you  live  alone? qY     qN  

q. Aids,  Alerts,  Devices,  etc. Other  

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 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________
4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters)

 Kidney Disease?  Liver Disease? BP = HR = RR = Y N NA Pregnant? Trimester:

CrCl = Y N NA Breastfeeding?
E.g. Diabetes 1. 2. 3.
Type II, diagnosed in ___
HgA1C = 7.2% (mm/yyyy)
Tests 3 times daily (blood glucose diary
copied and attached), sees foot specialist
on regular basis
4. 5. 6. 7.

8. 9. 10. 11.

Head to toe Assessment regarding other complaints/concerns/bothersome symptoms:

Complaints/Concerns:

Bothersome symptoms:

Do any ever require self treatment?

Family History

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 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________
5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)
Issues Identified
Medication How Taken Purpose for Use How long taken Yes: No: Additional
Name, Strength Dose, Route, Frequency, Time Proceed Verify to Comments
of Day, Special Instructions to DTPs continue
Identified as per

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 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________
6. Recently Discontinued Medications
Require Further
Medication How Taken Purpose for Use How long taken? Who stopped it? Action?
Name, Strength Dose, Frequency, Time of Day, When was stopped? Reason for Stopping? Yes: No:
Special Instructions Proceed Verify to
to DTPs continue
Identified as per

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 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________
Drug Therapy Problems Identified
 No drug therapy problems were identified

Priority Number Drug Therapy Problem (DTP)

_____ _________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

For those drug therapy problems above which can be corrected with immediate action and no
further research or consultation, document your plan below:

DTP Proposed solution Discussed Follow-up Plan

# with
patient

For those drug therapy problems requiring further research, contact with other health care
providers and care plan development, utilize the Pharmacy Care Plan worksheet.

____________________________________ __________________________
Pharmacist signature Date of Review
 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________

Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have
collected.

Assessment: State the drug therapy problem.

Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence,
cost, drug coverage and non-pharmacological interventions.

Alternative #1:

Alternative #2:

Monitoring:

Planned date of follow-up: ____________________________

____________________________________ __________________________

Pharmacist signature Date of Review

 Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB: Phone:
Pharmacist: _____________________
Patient Action Plan
Date of Comprehensive Medication Review: _________________________

As a result of my comprehensive medication review, I will do the following:

1.

2.

3.

4.

5.

6.

7.

Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association.
(2010). Program Guidance Document, NB Pharmacheck.
 Pharmacy  Contact  Information  Here  

Patient  Name:  
PHIN:
 DOB:   Pharmacist:  
Phone:

Patient  Follow-­‐Record  

Date  of  Follow-­‐Up   Reason  for  Follow-­‐up   Results   Pharmacist  Comments  &  Plan  
Intervention  complete?  q Yes     q No  

Any  new  concerns?  

Pharmacist  signature:  
Intervention  complete?  q Yes     q No  

Any  new  concerns?  

Pharmacist  signature:  
Intervention  complete?  q Yes     q No  

Any  new  concerns?  

Pharmacist  signature:  

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 Health Care Practitioner Communication Form
Date:_______________________

Health Care Practitioner Re: (Patient’s Name) PHIN

Pharmacy Contact Information Here

Address Address

Phone # Fax # DOB Phone #

Pharmacist: _____________________

Dear Dr._____________________,
Your patient had a Comprehensive Medication Review completed on ________________. Listed below are my assessment(s) and recommendation(s). Please
provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me.

Drug Therapy Problem Pharmacist Recommendation Make Changes as Prescriber

Recommended Comments/Revisions
Information Only Action Required 
Yes No

Information Only Action Required 

Yes No

Pharmacist Name: Prescriber Signature:

License #: License #: Date:

THIS TELECOPY IS CONFIDENTIAL AND IS INTENDED TO BE RECEIVED BY THE ADDRESSEE ONLY. IF THE READER IS NOT THE INTENDED RECIPIENT THEREOF, YOU ARE ADVISED THAT ANY DISSEMINATION, DISTRIBUTION OR
COPYING OF THIS FACSIMILE IS STRICTLY PROHIBTED. USE OF THIS FORM FOR PURPOSES OR BY PERSONS, NOT AUTHORIZED UNDER THE CONTROLLED DRUGS AND SUBSTANCES ACT AND ITS REGULATIONS IS A CRIMINAL
ACT. PRACTITIONER CERTIFICATION: THIS PRESCRIPTION REPRESENTS THE ORIGINAL OF THE PRESCRIPTION DRUG ORDER, THE PHARMACY ADDRESSEE NOTED ABOVE IS THE ONLY INTENDED RECIPIENT AND THERE ARE NO
OTHERS, THE ORIGINAL PRESCRIPTION HAS BEEN INVALIDATED AND SECURELY FILED AND IT WILL NOT BE TRANSMITTED ELSEWHERE AT ANOTHER TIME, QUANTITY MUST BE STATED IN WORDS AND NUMERALS
Form adapted from: The Ontario Pharmacists Association, MedsCheck.

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