1.Ask open-ended questions at the start of the interview and then move to more direct and targeted questions as the interview proceeds.

e.g., to ask the patient to describe any medications taken daily;
e.g., to ask the patient to describe the size, shape, and color of the medication regularly taken (a more direct and targeted question).

2.Avoid asking leading questions, multiple questions, and excessive yes/no questions.

e.g., a leading question such as "Does your tuberculosis medication turn your urine red?" may make the patient think the medication is supposed to turn the urine red and that something is wrong with the patient if his or her urine is not red.

3.Probe for medication-related effects by asking more general questions.

e.g., "How are you tolerating your tuberculosis medications?", "Have you noticed anything different or unusual since you started taking the medication?"

4.Avoid the trap of asking a series of rapid-fire questions without giving the patient time to answer. Give the patient ample time to address each question before asking another question.

5.Getting into a pattern of asking a series of yes/no questions also is very easy, especially toward the end of the interview, when the pharmacist asks specific and targeted questions.

This type of rapid-fire yes/no questions creates one-sided conversations and may diminish the flow of information from patients.

e.g., "Do you take anything for headache?", "Do you take anything for your eyes?", "Do you take anything for your heart?", "Do you take anything for your breathing?", "Do you take anything when you have a cold?", "Have you ever taken penicillin?"

6.Encourage patients to talk about their experience with medications.

Demographic Information

  • Age/date of birth
  • Height and weight
  • Race and/or ethnic origin
  • Type of residence
  • Education
  • Occupation
  • Lifestyle

Housing situation (e.g., loarding hourse, private home, apartment, shelter, living on the street)

The people living with the patient (e.g., spouse, young children, elderly relatives, extended family)

The patient's type of work and work schedule (i.e., day shift, night shift, rotating shift schedule, part time, full time)

Dietary Information

  • Dietary restrictions
  • Dietary supplements
  • Dietary stimulants
  • Dietary suppressants

Social Habits

  • Tobacco use

Packs per day/ppd

pack-years/pk-yr (e.g., 2 ppd for 5 years; 10 pk-yr)

  • Alcohol use (Men, women, respectively)

Lifetime abstainer

Former infrequent drinker

Current drinker

Infrequent drinker

Light drinker

Moderate drinker

Heavier drinker

Binge drinker

  • Illicit drug use

Document the duration of use, amount of each agent consumed, frequency of use, and reasons for use of each agent without being judgemental.

Determine the type, quantity, pattern, and duration of alcohol use.

Screen Shot 2016-04-06 at 6.46.32 PMTo assess tobacco use, note at what age the patient first started smoking tobacco and when the patient quit smoking (if applicable). One pack-year is equivalent to smoking one pack of cigarettes daily for 1 year. A 10 pk-yr tobacco history is quivalent to smoking 0.5 ppd for 20 years, 1 ppd for 10 years, or 2 ppd for 5 years.

Illicit drug use may be difficult to ascertain. Obtain this information in a professional, nothreatening, nonjudgmental manner. Do not try to guess which patients are more or less likely to use these agents but probe for this information with every patient. 


Current Prescription Medications

  • Name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (prescribed and actual, and reason for discrepancy)
  • Dose schedule (routine times patient taking each dose, prescribed and actual, and reason for discrepancy)
  • Reason for taking the medication (including clarification any discrepancies regarding customary uses of medications with the prescriber)
  • Start date (exact date, duration of therapy)
  • Outcome of therapy

Medication Names

Patients may not be able to remember the names of all their medications. If this is the case, obtain a detail description of each medication, including the dosage form (e.g., tablet, capsule, liquid, topical formulation); size, shape, and color of the dosage form; and any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form. If the patient cannot remember the dosage of the drug, the pharmacist may be able to identify the drug and/or dosage from other details the patient provides. However, clearly document the patient's description and note that the medication might be a specific product.

Many physicians, nurses, and other health care profesionals typically know the proprietary (trade) name of the medication but are less familiar with the nonproprietary (generic) medication names. Therefore when a patient identifies a medication by the proprietary name, document both the proprietary and nonproprietary names. If the patient identifies a medication by the nonproprietary name, document the nonproprietary name. For combination medications, document the nonproprietary names of all active ingredients in the bombination  product.

Dose Schedule

Obtain the prescribed dosing schedule (e.g., four times a day, two times a day, once a day) and note the routine times the pateint takes each dose. If a discrepancy between the prescribed dosing schedule and the schedule the patient uses is apparent (e.g., the patient is supposed to take the medication four times a day but takes it two times a day), note the discrepancy and try to determine the reason the patient uses the drug differently from the way it is prescribed.

Reason for Taking the Medication and Start Date

Determine when the patient started taking the prescription medication and the reason the pateint gives for taking the medication. Exact dates are important in determining whether an adverse or allergic reaction is a result of a specific medication and whether the prescribed medication is effectively treating or controlling a specific condition. For example, a patient with elevated blood pressure may claim to adhere to his or her blood pressure medication regimen yet still have elevated blood pressure. The decision to continue or discontinue the medication depends on when the patient started the current regimen. The regimen would continue unchanged if the patient has just started the medication the previous week but would need to be changed if the patient had been taking the medication for 2 months. Some pateints may not known the specific reason they are taking their medications because they forgot or misunderstand the reason it has been prescribed. Document the reasons the patient gives for taking the medication and clarify any discrepancies regarding customary uses of medications with the prescriber, not the patient.

No Demand (prn) Medications

For as needed (prn, on demand) prescription and nonpresctiption medications, document the possible use as well as the patient's actual use of the medication. Quantification is important; do not accept imprecise descriptive terms. Patients may or may not be able to describe their frequency of use but may be able to describe how often they get the prescription refilled or buy a new supply of nonprescription medication; both given an indirect indication of frequency of use. One approach to quantifying the amount of medication actually consumed by the patient is to inquire how often the patient has to obtain a new supply of the medication.

Past Prescription Medications

  • Name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (prescribed and actual, and reason for discrepancy)
  • Dose schedule (routine times patient taking each dose, prescribed and actual, and reason for discrepancy)
  • Reason for taking the medication (including clarification any discrepancies regarding customary uses of medications with the prescriber)
  • Start date (exact date, duration of therapy)
  • Stop date (exact date, duration of therapy)
  • Reason for stopping
  • Outcome of therapy

Knowledge of past prescriptions helps the pharmacist understand the medications used, either successfully or unsuccessfully, to treat current and past medical problems; this knowledge guides recommendations regarding new medication regimens. Patients are unlikely to remember all these details for past medications. Document the details the patient can remember; avoid excessive "grilling" of the patient.

Current Nonprescription Medications

  • Name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (recommended/prescribed and actual, and reason for discrepancy)
  • Dose schedule (routine times patient taking each dose, recommended/prescribed and actual, and reason for discrepancy)
  • Reason for taking the medication (including clarification any discrepancies regarding customary uses of medications with the prescriber)
  • Start date (exact date, duration of therapy)
  • Outcome of therapy

Knowledge of current nonprescription medications allows the pharmacist to determine whether drug interactions may occur between prescribed and self-administered medications, whether the patient is self-medicating to relieve an adverse drug reaction from a prescribed medication or in an attempt to obtain better relief from symptoms than that provided by the prescribed regimen, and whether a nonprescription medication is the cause of a patient's complaint or is exacerbating a concurrent medical condition.

Past Nonprescription Medications

  • Name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (recommended/prescribed and actual, and reason for discrepancy)
  • Dose schedule (routine times patient taking each dose, recommended/prescribed and actual, and reason for discrepancy)
  • Reason for taking the medication (including clarification any discrepancies regarding customary uses of medications with the prescriber)
  • Start date (exact date, duration of therapy)
  • Stop date (exact date, duration of therapy)
  • Reason for stopping
  • Outcome of therapy

Knowledge of past nonprescription regimens gives the pharmacist insight regarding past medical problems or attempts to treat current medical problems.

Current and Past Complementary and Alternative Medicines

  • Name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (recommended/prescribed and actual, and reason for discrepancy)
  • Dose schedule (routine times patient taking each dose, recommended/prescribed and actual, and reason for discrepancy)
  • Reason for taking the medication (including clarification any discrepancies regarding customary uses of medications with the prescriber)
  • Start date (exact date, duration of therapy)
  • Stop date (exact date, duration of therapy)
  • Reason for stopping
  • Outcome of therapy

Approximately 7% of Americans take complementary and alternative medicines (e.g., herbal remedies, megavitamins, homeopathic medicine, folk remedies). However, the majority of people do not discuss these therapies with their physicians. Many of these medicines interact with traditional medicines. Some have significant side effects. Therefore, it is important to document the use of these medicines.

Ask the patient follow-up questions to clarify why the patient is taking the alternative medicine. For example, if a patient states that he or she is taking an alternative medicine to boost the immune system, ask the patient whether anyone has ever told the patient that he or she has a weakened immune system and whether the patient gets more infections than most people.

Medication Allergies

  • Drug name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (recommended/prescribed and actual, and reason for discrepancy)
  • Date of reaction
  • Description of reaction
  • Treatment for the raction

Many physicians, nurses, and other health care professionals as well as patients may be unable to differentiate between a drug allergy and an adverse drug reaction. But it is very important to try to distinguish between the two reactions. Once a medication allergy is documented for a patient, it is highly unlikely that the patient will receive the medication or a similar medication again. If the reaction was a manageable or acceptable adverse reaction rather than an allergic reaction, however, the patient may be unnecessarily denied access to potentially useful medications. The term allergy indicates hypersensitivity to specific substances. Drug-induced allergic reactions include anaphylaxis, contact dermatitis, and serum sickness.

A useful first step is to ask patients whether they are allergic to any medications and then probe for the details of the problem, depending on the response. Ask patients if they have ever experienced rashes or breathing problems after taking any medications. Patients may not correlate a rash with an allergy, so it is important to probe for these details.

After a medication has been identified as the cause of an allergic reaction, ask the patient to provide details regarding the time or date of the allergic reaction and any interventions instituted to manage the reaction, and inquire whether the patient has received the medication since first experiencing the allergic reaction. Ask whether medications in similar drug classes have been taken without the occurrence of a similar reaction (i.e., “Have you taken any antibiotics since you found out you were allergic to penicillin?”).

Adverse Drug Reactions

  • Drug name (proprietary and nonproprietary) and/or description

Dosage form (e.g., tablet, capsule, liquid, topical formulation)

Size, shape, and color of the dosage form

Any words, letters, and numbers on the dosage form that the patient can remember or that can be seen on the dosage form

  • Dose (recommended/prescribed and actual, and reason for discrepancy)
  • Date of reaction
  • Description of reaction
  • Treatment for the raction

Ask patients whether they have ever taken a medication they would rather not take again. This question often elicits specific descriptions of adverse reactions the patient has experienced.


Immunizations

  • Name of vaccines
  • Date each vaccine was administered

Vaccinations are important for the health of individuals and the public. The CDC immunization recommendations are complex and difficult for an individual patient to understand.

Adherence

One of the goals of the medication history interview is to determine whether the patient is adherent to prescribed or recommended medication regimens. Knowledge regarding patient adherence is useful in evaluating the effectiveness of prescribed or recommended medication regimens. Medications may be ineffective if the patient does not comply with the prescribed or recommended regimen. Nonadherence may result in additional diagnostic evaluations, procedures, hospitalizations, and unnecessary combination medication regimens.

Adherence is difficult to determine through direct questioning. Patients know they are supposed to take their prescribed and/or recommended medications. When confronted by an authority figure, patients most likely will say they are adherent even if they are not. Therefore evaluate the patient's adherence by gentle probing throughout the interview. Clues about adherence may be obtained through patient descriptions of how they take their prescribed medications. Many patients can describe their medication routines in detail; other patients may not be able to describe any sort of routine or even recall the color or shape of the medication. Patients who can convincingly describe their medication routines are more likely to be adherent than patients who can provide only vague and general descriptions of their medications and routines.

Sympathetic confrontation may help the pharmacist obtain information regarding patient adherence. Patients are more likely to be truthful when describing their difficulties with complying with the medication regimen if the pharmacist acknowledges that the dosage regimen is complex and difficult to follow and that taking medication regularly is hard. Remain nonjudgmental when assessing patient adherence; this attitude encourages the patient to trust the pharmacist and tell the truth about adherence to prescribed medication regimens.