Form 2: Personal Medication Record

Personal Medication Record **sections in red are optional** Name: Last, First (Gender) Allergies: No known allergies Primary Physician Date of MedsCheck: (DD/MM/YY) OHIP #: Product Reaction (name, phone & CPSO number)

D.O.B: Telephone: (DD/MM/YY) Current Smoking Status Yes, currently smoke No, former smoker No, never smoked

Medication, Dosage & Form Pharmacist comments Date Dispensed Quantity (Special instructions such as no action, Purpose for Use (Brand or generic / manufacturer Direction of Use Am Noon Supper Bedtime dispensed record discrepancy, medication to (DD/MM/YY) as known by the patient) continue, referred to another HCP, etc.) Prescriptions (including nasal sprays and eye drops)

OTC/Herbal

Pharmacist recommendations & comments for patient:

Pharmacist Name: ______Pharmacist Contact Information: Pharmacist Signature ______Patient Signature Pharmacy Name, Address and Telephone Number are mandatory Pharmacy Logo is optional Page of .

Note: MedsCheck is a voluntary program sponsored by the Ontario government. The accuracy of the information in this document depends on the accuracy and completeness of the information provided by the patient at the time the M edsCheck was prepared. The signed and dated MedsCheck demonstrates that both parties have an understanding of the MedsCheck program and the process; the completed MedsCheck may be shared with other health care profession als within the circle of care. Personal Medication Record Continued: Name: Last, First Telephone: Primary Physician : Date of MedsCheck(DD/MM/YY):

Medication, Dosage & Form Pharmacist comments Date Dispensed Quantity (Special instructions such as no action, Purpose for Use (Brand or generic / manufacturer Directions of use Am Noon Supper Bedtime dispensed record discrepancy, medication to (DD/MM/YY) as known by the patient) continue, referred to another HCP, etc.) Prescriptions (including nasal sprays and eye drops)

OTC/Herbal

Page of .

Note: MedsCheck is a voluntary program sponsored by the Ontario government. The accuracy of the information in this document depends on the accuracy and completeness of the information provided by the patient at the time the M edsCheck was prepared. The signed and dated MedsCheck demonstrates that both parties have an understanding of the MedsCheck program and the process; the completed MedsCheck may be shared with other health care profession als within the circle of care.