Form Pd903991 - Medco Pharmacy Mail-Order Form Page 3
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4Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
We will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, we
need to know if you have any medication allergies or medical conditions. We also need to know what prescription and
nonprescription medications you take regularly.
Your privacy is important to us. We comply with federal privacy regulations and will protect this information.
Follow the steps listed below.
Step 1: Verify and complete information in SECTION 1.
Step 2: Complete all sections below using blue or black ink. Please print.
Step 3: Return the completed questionnaire in the self-addressed envelope with your mail-order form or refills. If you
do not have a preaddressed envelope, please return the questionnaire to:
Medco Health Solutions, Inc.
4865 Dixie Highway
Fairfield, OH 45014
Attn: HMQ
SECTION 1: Patient information
Patient name:
Gender:
Month/Year of birth:
Contact phone:
Patient member number:
(Located on your ID card.)
SECTION 2: Your medication allergies
Fill in the oval completely if you have had an allergy or serious reaction to any of these medications:
Aspirin and salicylates (for example: ZORprin
®
, Trilisate
®
)
Codeine (for example: Tylenol
®
#3)
Erythromycin, Biaxin
®
, Zithromax
®
Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil
®
, Motrin
®
)
Penicillins/cephalosporins (for example: Amoxil
®
, amoxicillin, ampicillin, Keflex
®
, cephalexin)
Sulfa drugs (for example: Septra
®
, Bactrim
®
, TMP/SMX)
Tetracycline antibiotics
If you have an allergy to a medication that is not listed above, print the name of that medication
in the space below. Example: morphine
other:
other:
(over, please)
(over, please)
PD903991
7/10
04/09
A030
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