Best Possible Medication History (BPMH) - Patient Section

Pharmacy Name (and/or Logo) Prepared by (Pharmacist Name)
and Address
College Registration ID
Prepared on (yyyy-mm-dd)
Pharmacy Phone # (10 digits) Page of Pages
BEST POSSIBLE MEDICATION HISTORY (BPMH)—Patient Section
PATIENT
First Name: PHN: Gender:
Last Name: Date of Birth: Phone #:
FAMILY PHYSICIAN
Full Name: Phone #: Fax # (if known):
KNOWN ALLERGIES AND REACTIONS (if applicable) - Pharmacist: PLEASE PRINT
MEDICATIONS I TAKE—Prescription, non-prescription, natural health products - Pharmacist: PLEASE PRINT
Patient is not taking any non-prescription or natural health products at this time.  (Check box or give product details below)
WHAT I TAKE WHY I TAKE IT HOW I TAKE IT SPECIAL INSTRUCTIONS

Name, strength & form of medication Disease, condition or For example, when to take it, (if applicable)
as noted on the prescription or symptoms it addresses take with/without food,
medication package label warnings, etc.
PATIENT ACKNOWLEDGEMENT
My pharmacist has explained to me the purpose of a medication review service. I agreed that I could benefit from this publicly funded service.
The review was conducted in a place that respected my privacy. During the appointment my pharmacist fully explained any medication changes
or concerns to me. At the end of the medication review appointment, my pharmacist gave me a list of my current medications. The list includes
any changes resulting from the medication review service provided.
Signature of patient (or patient’s legal representative) Date
Attention Health Care Professionals: A more detailed version of this Medication History that includes professional notes is available from the pharmacy named above.
Sources of information in this document include (but are not limited to) PharmaNet, local pharmacy data and the patient. The patient is responsible for the accuracy
and completeness of the data they provided when this document was prepared and for advising the pharmacist of any change to these medications. The pharmacist is
responsible for information in this document that changed as a result of providing a medication review service to the patient.
Pharmacy Name (and/or Logo) Prepared by (Pharmacist Name)
and Address
College Registration ID
Prepared on (yyyy-mm-dd)
Pharmacy Phone # (10 digits) Page of Pages
Patient’s First Name Patient’s Last PHN
Name
BEST POSSIBLE MEDICATION HISTORY (BPMH)—Health Care Professionals Section

CLINICAL NEED FOR SERVICE
Prescriber:  requested a medication review
Patient: (check one or more)
 has multiple diseases  has a medication regimen that includes one or more Or, for an MR-F (Follow-up), follow-up is: (Check one)
 has one or more chronic natural health products  due to a subsequent medication change (i.e, a
diseases  has a drug therapy problem change in a medication entered on PharmaNet),
 has a medication regimen that  has been recently discharged from hospital or
includes one or more  has multiple prescribers  to implement and /or evaluate patient’s response
non-prescription medications  takes medication(s) that require laboratory monitoring to the action taken to resolve a DTP.
CURRENT MEDICATIONS
NAME OF DRUG & PRESCRIBER NAME & VERIFIED ACTION NOTES
STRENGTH PROFESSION Continue as per 1 = For example: Drug Therapy (if applicable)
For example, physician/MD, PHARMANET, 2 = PATIENT Problem plan, referral,
RPN, naturopath, (different than PharmaNet), follow up required
pharmacist, patient or 3 = PATIENT (not in
PharmaNet).
8
CLINICALLY RELEVANT MEDICATIONS THE PATIENT IS NO LONGER TAKING (if applicable)
NAME & STRENGTH WHY IT WAS TAKEN MOST RECENT WHO STOPPED IT COMMENTS
OF DRUG REGIMEN Name of prescriber, pharmacist, Reason for stopping, effectiveness,
other or patient other relevant information
Attention Health Care Professionals: Sources of information in this document include (but are not limited to) PharmaNet, local pharmacy data and the patient. The
patient is responsible for the accuracy and completeness of the data they provided when this document was prepared and for advising the pharmacist of any change to
these medications. The pharmacist is responsible for information in this document that changed as a result of providing a medication review service to the patient.

Best Possible Medication History (BPMH) - Patient Section

Uploaded by

Copyright:

Available Formats

Best Possible Medication History (BPMH) - Patient Section

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Best Possible Medication History (BPMH) - Patient Section

Uploaded by

Copyright:

Available Formats

Pharmacy Name (and/or Logo) Prepared by (Pharmacist Name)

BEST POSSIBLE MEDICATION HISTORY (BPMH)—Patient Section

MEDICATIONS I TAKE—Prescription, non-prescription, natural health products - Pharmacist: PLEASE PRINT

WHAT I TAKE WHY I TAKE IT HOW I TAKE IT SPECIAL INSTRUCTIONS

BEST POSSIBLE MEDICATION HISTORY (BPMH)—Health Care Professionals Section

You might also like