Are you getting the most from your medications?
What benefits are there from having a Medication Review?
Address any questions or concerns that you have about your medicine
Ensure that you are receiving the best medicine therapy possible
Increase your knowledge and confidence about your medicine
Reduce your risk of problems from your medicine
Am I a good candidate for a Medication Review?
Are you taking several medications or worry that you take too many (including natural products and non-prescription products)?
Do any of your medications make you feel unwell?
Are your prescriptions unaffordable or have you not taken a prescribed medication because it is too expensive?
Do you have trouble understanding or remembering how to take yourmedicine?
Do you ever have trouble using your medicines (swallowing, puffers, eye drops, patches)?
Do you worry that your medicines are working against each other?
Do you wish you knew more about your medicine?
* If any of any of these apply to you, schedule a visit with our pharmacist to review all your medications. This visit may take up to 60 minutes.
Please remember to bring all medications (including over the counter, herbal, vitamins, etc.) to your appointment along with the back of this form filled out. If you turn in this form before your appointment, it will help the pharmacist look into any concerns you may have before your appointment.
Location choice: Choose...West LibertyIndian LakeBellefontaineWLS Schools
Pharmacies used to fill prescriptions Choose...AriesCommunity MarketCVSC&RKroger BellefontaineKroger UrbanaMyPharmacyRite Aid BellefontaineRite Aid Indian LakeWalgreens BellefontaineWalgreens Indian LakeWalgreens UrbanaOther (list below)
What is your primary concern about your medications today?
What would you like to achieve from your medication review?
List any over the counter, herbal, vitamins, etc that you regularly take:
Do you use a pill box to organize your medications? Choose...yesno
Do you sometimes forget to take your medications? Choose...yesno
Have you ever decreased or quit taking a medication on your own? Choose...yesno
Do you feel hassled by taking your medications? Choose...yesno