PATIENT NO:
Patient Medication Profile
A. PATIENT INFORMATION:
The patient agrees to provide information and will be gathered as for reference purposes only.
Name, residence and contact information will be considered private: Yes ________ No __________
Patient Name: Age:
Address: Gender:
Contact no.: Religion:
Occupation: Civil Status:
Height: Weight:
Blood Pressure:
Blood Sugar level:
Date of last doctor consultation:
Date of Recent Physical Examination/ Laboratory results/ X-Ray:
Current State of Health: (Put check mark that applies)
Heart disease Asthma
High Blood Pressure Hyperacidity
Stroke Eye Problem
Diabetes Cough/Colds
Hyperlipidemia Skin Allergy
Cancer (specify): Diarrhea
Tooth ache/Dental Issues
Arthritis Skin Infection (Specify)
Body pain Wound
Others (Please specify): _______________________________________________________________
Vaccination: Yes _____ No _______ If Yes see table below for details:
Vaccine/ Biologicals Date administered: (month/ year)
COVID 19 Vaccine
Flu Vaccine
Other
CURRENT MEDICATION USE (VITAMINS/SUPPLEMENTS INCLUDED)
Drug Name: Strength Indication Usage Start Date Stop Date Prescribed
Generic or by Doctor?
Brand Name Yes/No
B. RESPIRATORY CONCERN:
1. Have you been sick with cough? Yes __________ No ______________
2. What type of cough? ____ w/phlegm ____ dry _____w/ sore throat ____w/asthma _____ allergy
3. How long your cough last? _______ day ________ week _______ month ________ year
4. What medication you used? _________________________________________________________
5. How do you used the medication and how long you used it? _______________________________
6. Is the medication prescribed? Yes ________ No ____________
7. Are you familiar with TB DOTS? Yes _______ No ____________
C. REPRODUCTIVE HEALTH
1. Are you married? Yes __________ No __________________
2. Do you have children? How many? Yes ________ None __________ No. of Children __________
3. Have you use contraceptive device? Yes __________ No ______________
4. Are you familiar with vasectomy? Yes _________ No __________________
5. Have your wife/partner use contraceptive medicine or device? Yes _______ No _____
6. What product or brand? __________________________________________
D. DRUG PERCEPTION:
1. Do use/believe on Generic Drug: Yes: ___ No: _____ Why? : ___________________________
2. Do you take antibiotic without doctor’s advice? Yes ___ No ___ If Yes Why? ________________
E. RECOMMENDATION OF COUNSELOR:
PARTICULAR PUT CHECK MARK
Consult a physician
Consult a pharmacist
Perform exercise
Take maintenance medicine regularly
Take vitamins/supplements regularly
Eat healthy food/Diet
Regular BP check
Regular Blood Sugar Check
Other:
F. RECOMMENDED PRODUCT TO USE:
NAME OF PRODUCT PUT CHECK MARK INSTRUCTION FOR USE QUANTITY
Ascorbic Acid Cap/Tab
Multivitamins/Minerals Cap/Tab
Vitamin B Complex Cap/Tab
Food/Herbal Supplement
Other Products
REMARKS:____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ATTENDING PHARMACIST:
NAME : _________________________________________________________________
SIGNATURE : _________________________________________________________________
