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MTM Intake Form—This brief medical information form was sent with the MTM letter in advance of today’s appointment. The italicized information was completed by the patient. The patient has brought this form to today’s MTM visit.

Medication Therapy Management—Intake Form

Prescription/OTC Medicine(s), Vitamins, Herbals

If needed, place additional information on the back

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Livalo 2 mg, 1 daily in the evening

Fenofibrate 145 mg, 1 daily

Ezetimibe 10 mg, 1 daily

Current or Past Health Problems

Circle all that apply.

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Hypertension (high blood pressure)

Hyperlipidemia (high cholesterol)

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Diabetes

Arthritis

Depression

Anxiety

Congestive Heart Failure (CHF)

Heart Attack

Stroke

Other:

Allergies/Adverse Drug Events

Immunizations/Preventive Health

 

Flu shot date:

Pneumonia shot date:

Tetanus (Tdap/Td) date:

Vital Signs/Laboratory Results

Provide any recent results for these tests.

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Date

 

Date

 

Date

 

Blood pressure:

 

Total cholesterol:

 

Na:

 

Pulse:

 

LDL-C:

 

K:

 

Weight:

 

HDL-C:

 

Cl:

 

 

 

TG:

 

CO2:

 

Hg:

 

A1c:

 

SCr:

 

Hct:

 

TSH:

 

BUN:

 

What concern(s) do you have about your medication(s)?

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The Livalo is expensive and I’m having a hard time affording it now.

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