Pharmacy Intake Page 2
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2MEDICATIONS (List any medications, or give technician your list or circle none)
NONE
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ALLERGIES (List any allergies or circle no known allergies)
NO KNOWN ALLERGIES
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SOCIAL HISTORY (Circle all that apply)
Cigarette Smoking:
Illegal/Street Drugs:
Alcohol Use:
Drug use/IV Drug use
Never Smoked
None
Quit/Former Smoker
Less than 1 drink per day
Smokes Less Than Daily
1-2 Drinks per day
Smokes Daily
3 or more drinks per day
Circle any condition you are currently experiencing
EYES:
SKIN:
Sudden loss or change in vision
Rash
Burning or itching; excessive tearing
Excessive dryness
CONSTITUTIONAL:
NEUROLOGICAL:
Fever
Headache
Weight loss or weight gain
Loss of balance
EAR, NOSE & THROAT:
MUSCULOSKELETAL:
Sinus pressure/congestion
Arthritis
Hearing loss
Pain or swelling
HEART:
HEMATOLOGIC/LYMPHATIC:
Chest pain
Increased frequency of infections
Shortness of breath
Non-healing wounds
RESPIRATORY:
ALLERGIC/IMMUNOLOGIC:
Cough (sputum, blood)
Allergies to new medicines/foods/clothing
Wheezing
Hay fever
GASTROINTESTINAL:
PSYCHIATRIC:
Nausea/vomiting
Depression
Diarrhea
Anxiety
GENITOURINARY:
ENDOCRINE:
Incontinence
Increased urination or thirst
Blood in urine
Palpitations
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Parent category: Business