PHARMACIST MEDICATION REVIEW FORM by mh6bF4

VIEWS: 14 PAGES: 2

									                                                Shropshire County
                                                          Primary Care Trust


 CLINICAL CARE: PHARMACIST MEDICATION REVIEW FORM (with patient)

Name of Pharmacist conducting review:           Date of review:   Place of review:




PATIENT DETAILS:


Name/I.D:………………………………………….…….                          D.O.B…………………………..


Current Medical Conditions:                     Past Medical History:




Known allergies:………………………………………………………………………...


Record of Observations (most recent at the top):

Date:       Weight (kg):      BMI:         BP (mmHg)         Pulse:     Comments
                                                                        (if any)




Details of mobility:…………………………………………………………………………..

Details of any recent falls (if any):………………………………………………………..

Information on diet: e,g, liquidised/PEG/NG etc……………………………………….

Able to swallow tabs/caps?           Yes                 No      
Any other information: (e.g. changes in meds, smoking status etc.)
Current Medication:

Medicines:              Dose, frequency Understands   Comments or Problems
                        & quantity:     Purpose:      Identified:




RECOMMENDATIONS MADE:                            ACTION TAKEN:

								
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