The document is a medication history interview form for Pharm.D. internships at Integral University Faculty of Pharmacy, detailing sections to collect demographic data, chief complaints, medical history, current medications, and patient compliance. It includes assessments on allergies, immunizations, personal habits, diet, and exercise. Finally, it aims to evaluate the patient's understanding and compliance with medication instructions.

1. INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW
Medication History Interview Form
(Pharm.D. Internship)
1) Demographic and Social Information
Patient IP No: Age Gender Height Weight
Religion Occupation Pregnant: Yes or No Breast feeding: Yes or No
2) Chief Complaints
3) History of Present Illness:
4) Past Medical History: 5) Past Surgical History:
6) Past Medication History: 7) Family History:
8) Immunization History:
Immunization Type Date Last Received
Influenza
Tetanus
BCG
Others:
9) Allergies (Medication and Food) /Adverse Reactions:
No. Product Name Type and Severity of Reaction

2. 10) Current Prescription Medications
Drug Brand Name Generic Name Indication Dose
Route of
Admin
Freq.
Days
1 2 3 4 5 6 7
11) Current Non-Prescription Medications/Herbal/Nutritional products and supplements
Drug brand name Generic name Indication Dose
Route of
admin
Freq
Days
1 2 3 4 5 6 7
12) Assessment of Outpatient Medication Compliance
a) Who is responsible for medication administration for this patient?
b) Does patient have any difficulty understanding or complying with medication instructions?
c) Barriers to medication adherence? If yes explain:
13) Diet and Exercise
a) Typical daily diet:
b) Able to conduct Activities of daily living (ADL)? Yes ( ) No ( ) (explain)
14) Personal Habits (Smoking, Alcohol)
Smoking Alcohol
a) Never smoked ( ) quit smoking ( ): When:
______________
b)How long did they smoke? ____ Years
 No use ( ) Social use: __________/week;
Quantity: ___________________
c)Smokes _____ packs/day  Regular use: __________/week;
d) Exposure to second hand smoke _____
hours/day
 Quantity: ___________________
Name & Sign. of Student Signature of Preceptor