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PATIENT MEDICATION QUESTIONNAIRE
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PATIENT MEDICATION QUESTIONNAIRE
| Due to the pharmacy benefit changes in the majority of the insurance companies our office deals with, we have found it imperative to obtain certain information concerning medications that may have been previously taken. Most insurance companies are requriing precertification for medications; we need your asistance. Please complete this form in the event your insurance company requires your medication to be precertified. | |||
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Name: ___________________________________________________
Date of Birth: _______________
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| Prescription Plan Name: _____________________________________ Insurance ID # ______________ | |||
| Regular Pharmacy Name & Phone #: _____________________________________________________ | |||
| 1) | Have you ever taken ANY of the medications listed below? (Check ALL that apply) | ||
| Ibuprofen | Naprosyn | Daypro | |
| (Motrin/Advil/Nuprin) | |||
| Naproxen (Aleve) | Voltaren | Lodine | |
| Relafen | Arthrotec | Oruvail | |
| Cataflam | Orudis KT | Other _______________ | |
| 2) | Please check which side effect(s) you experienced while taking these medications: | ||
| Abdominal Pain | Diarrhea | Stomach Upset Other _____________ | |
| Nausea | Ulcer | Medication was not effective | |
| 3) | Have you ever taken ANY of the medications listed below? (Check ALL that apply) | ||
| Pepcid | Tagament | Axid | |
| Zantac | Prilosec | Prevacid | |
| Maalox | Mylanta | Tums | |
| ANY medication for an Ulcer or Gastric Reflux | |||
| 4) | Have you ever been diagnosed as having ANY of the ailments listed below? (Check ALL that apply) | ||
| Heartburn | Peptic Ulcer | Duodenal Ulcer | |
| Reflux | Barrett's | Other ___________________________ | |
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Esophogitis
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| 5) | Have you demonstrated an allergic reaction, such as a rash, to Sulfa (Bactrim/Septra)? Yes / No | ||
| 6) | Do you currently take an anticoagulant medication (Coumadin/warfarin)? Yes / No | ||
| 7) | Do you currently take a low-dose aspirin (325mg or less) per day? Yes / No | ||
| 8) | Do you currently take any oral corticosteroids (i.e. Prednisone)? Yes / No | ||
| 9) | Do you have high blood pressure? Yes / No | ||
| What medication(s) do you take, if any, for lowering blood presure? ___________________________ | |||