GERIATRIC OUTPATIENT PHARMACY INTERVIEW
Name/Last 4:
Age:
Gender: M / F Race:
Last Visit:
Purpose of Visit:
Why does the patient think they are here?
General Appearance
Y N cane/walker
Y N glasses
Y N hearing aids
Social History
Y N alcohol
Y N tobacco
Medication Adherence
Refill Method:  phone  mail
Refills on time:  Yes  No
Date:
Confirm Allergies:
Medication Management
Y N Arrives with meds
Y N Carries medication card
Y N Medichest
Y N Storagelocation__________
Y N Medication assistance_____________
Y N Med reminders/alarms, etc
Medication ADL’s
Y N Young children at home
Y N Can read label
Y N Comprehends label instructions
Y N Can open bottle
Y N Pills in appropriate bottle
Y N Other Pharmacy (location, meds):
Medication Reconciliation
(review prescription medications)
1. Medication Regimen Discrepancies
Missed dose:
daily  weekly monthly
What happens if you miss a dose:
 take when remember
 double next dose
 skip dose
(i.e., changes in dose, frequency, product)
2. Non-VA OTC Meds (if so list)
Y N Vitamins
Y N Herbals/Natural Products
3. Other Medications
Side Effects?
If so, clarify ADR vs SE
How long?
What did they do when they had the
SE?
Questions/Comments/Concerns?
OTC REVIEW OF SYSTEMS/HEAD-TO-TOE ASSESSMENT
CIRCLE PRODUCT, NOTE FREQUENCY/DOSE
HEENT
Headache: Tylenol (acetaminophen) – Advil/Motrin (ibuprofen) – Exedrin –
Aleve (naproxen) – Bayer/St. Joseph/Bufferin/Ecotrin (aspirin)
Eyes (i.e., dry, itchy, red): Visine – Clear Eyes – Renu – Alcon OptiFree Replish
Eye – AMO Complete Moisture Plus
Nasal/Sinus (i.e., runny nose/congestion): Sudafed/Sudafed PE – Benadryl
(diphenhydramine) – Afrin/Dristan/Vick’s Sinex Nasal Spray
(oxymetazoline) – Zicam – Saline Spray Claritin/D – Zyrtec – Primatene
Mist – Alavert – Mucinex – TheraFlu – Coricidin HBP – Combination
Products (Tylenol Cold & Sinus)
Oral (i.e., cough, sore throat): Nyquil/Dayquil – Robitussin – Delsym – Mucinex
– Vick’s Vapor Rub – chloraseptic spray – lozenges/cough drops –
Coricidin HBP – Combination Products (Tylenol Cold & Sinus) – Dimetapp
Dizziness: Antivert/Bonine (meclizine) – Scopolamine – Dramamine
Fatigue: No Doz/Vivarin (caffeine)
Sleep: Compoze/Simply Sleep/Nytol/Unisom/Benadryl (diphenhydramine) –
Tylenol PM – Melatonin – Exedrin PM – Advil PM – Goody’s PM
GI/Bladder
Nausea/Vomiting: Antivert/Bonine (meclizine) – Scopolamine – Dramamine –
Philips (milk of magnesia) – Gas X – Mylanta – Pepto Bismol/Kaopectate
(bismuth)
Heart Burn / Indigestion: Tums – Prilosec (omeprazole) – Alka-Seltzer –
Mylanta –Maalox Rolaids – Alamag – Caltrate – Zantac (ranitidine) – Milk
of Magnesia – Pepcid (famotidine) – Tagamet (cimetidine)
Diarrhea: Imodium (loperamide) – Pepto Bismol/Kaopectate (bismuth)
Constipation: Metamucil (psyllium) – Senna/S – Colace (docusate) – Dulcolax
(bisacodyl) Citrucel – Fibercon – Fleet – Miralax – mineral oil – Benefiber
– Fiber Chioce – Ex-Lax
Pain
Location:_______________ Scale (0-10):___________
Tylenol (acetaminophen) – Advil/Motrin (ibuprofen) – Exedrin –
Bayer/St.Joseph/Bufferin/Ecotrin (aspirin) – Aleve (naproxen) – Icy Hot –
Bengay – capsaicin – glucosamine
Any other complaints?