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Patient Interview Format

  • Introduction

    • My name is _________ and I am a pharmacy intern. May I verify your name and date of birth?

  • Goal of interaction

    • I want to get some health information from you to help better take care of you.

  • Chief Complaint/History of Present Illness (CC/HPI)

    • What brings you to the pharmacy today? How are you feeling today? What problems are you having with your medications?

      • Reason for getting a new prescription filled

    • What brings you to the hospital/clinic today? How are you feeling today?

      • Reason for hospital admission or clinic visit

    • Past Medical History (PMH)

      • What medical problems have you been diagnosed with?

    • Social History (SH)

      • How much do you smoke, or drink, if at all?

      • What illicit substances do you use, if any?

      • If applicable: What types of foods do you eat? How much do you exercise? How often?

    • Family History (FH)

      • What medical problems do your parents/siblings have?

    • Medication History

      • What prescription or over-the-counter (OTC) medications do you take at home and what do you take them for?

      • How often do you miss a dose of your medication for any reason at all?

      • How do you take your medication? (if applicable when medication must be administered in a certain way)

    • Allergies

      • What allergies do you have? What is your reaction?

    • Closing

      • Is there anything else you think that I should know about your current condition?

      • Thank you for providing this information. I will speak with my pharmacist and then get back to you with a plan.

Patient Presentation Format

  • Introduce Patient

    • Patient name or initials is a ____-year-old male/female

  • Chief Complaint (CC)

    • Main symptom or reason stated by patient

  • History of Present Illness (HPI)

    • What led to patient seeking help?

  • Past Medical History (PMH)/Past Surgical History (PSH)

  • Pertinent Family History (FH)

    • Medical problems in first-degree relatives

  • Pertinent Social History (SH)

    • Smoking habits, drinking habits, illicit drug habits

    • Diet and exercise (if applicable)

  • Medication History

    • Prescription and over-the-counter (OTC) medications the patient currently takes at home

      • Include drug name, dose, route, and frequency

      • Include overall adherence

  • Allergy information

  • Pertinent objective data (vitals, labs, imaging, etc.)

  • Prioritize the problems and state problem #1 for patient (most important problem, most relevant)

    • Include goals of therapy, risk assessments, etc.

    • State guidelines

    • State plan for this problem (eg, start, stop, adjust medication(s) based on patient interview and/or symptoms)

    • What to monitor (lab value, possible side effects)

    • Include nonpharmacological interventions

  • Repeat previous step for each problem.

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