When it comes to managing your patient’s medications, having access to an up-to-date and accurate medication list is critical in maintaining their health. A patient medication history form can provide a detailed overview of the medications a patient is currently taking and also any they may have taken in recent years. The information collected on this form can help point healthcare professionals towards potential problems or drug interactions while providing valuable insights into treatments being used by the patient over time. In this blog post, we'll discuss how having a complete understanding of your patient's medication history with a dedicated and comprehensive form can give you the data needed for optimal health outcomes.
| Question | Answer |
|---|---|
| Form Name | Patient Medication History Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | form medicines sample, fill in medication form, form medications printable, medication history you |
Patient Medication History Form
This form can also be found at www.uwmedicationlist.org
The medicines you take are part of your health information. Please fill out this form (or have your caregiver complete it) and discuss it with your medical provider. If you need more space to list your medicines, ask for another form. Please do not write on the back of this form.
Patient Name:______________________________________________________________________ Page #: ________
Allergies
Name of Substance (drug or food) |
Type of Reaction |
Check if none
Do you react to latex or rubber (gloves, balloons, etc) with a rash, wheezing, etc.? For female patients ONLY: Are you currently pregnant?
Are you considering becoming pregnant? Are you currently breastfeeding?
Yes
Yes
Yes
Yes
No
No
No
No
Current Medications
Prescription Drugs |
Strength |
Directions (such as 2 tablets in the a.m.) |
Prescribed By |
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(such as Atenolol, eye drops, creams) |
(such as 50 mg) |
Check box if taken only as needed. |
(such as John Doe, MD) |
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Check if none |
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Strength |
Directions (such as for headaches, when needed) |
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Check if none |
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Herbs, Vitamins, Minerals, Etc. (such as St. John’s Wort) |
Strength |
Directions (such as one tablet each day) |
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Check if none |
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Pharmacy Name: ________________________________________________ Phone #: ___________________________
STAFF ONLY |
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Medication list reviewed prior to any change/deletion/addition by licensed provider |
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Yes – |
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PT.NO
NAME
DOB
UW Medicine Health System
Harborview Medical Center – UW Medical Center
Northwest Hospital & Medical Center – University of Washington Physicians Seattle, Washington
PATIENT MEDICATION HISTORY
DO NOT THIN on FLOOR, |
WHITE – OUTPT: PATIENT COPY |
SCAN or FILE IN MED |
CANARY - PHARMACY |
RECORD |
WHITE – H&P OR |
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UH2301 REV DEC 10