History Form

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Patient History Form
Patient Information: To be filled out by the Patient
Name:________________________________._ Home Phone #  ( ____ ) ______ – ________
Address: ______________________________ Home Fax #      ( ____ ) ______ – ________
City: __________________________________ E-mail address: _______________
State: _________________________________ Sex:  M__ F__
Zip Code: _________________ Birth Date: ____________________
Do you have any drug allergies?  Yes ___ No ___
If Yes please explain: _____________________________________________________
___________________________________________________________________
Physician Information:
Primary physician name:_____________________________ Phone: ( ____ ) ______ – ___________
Address:__________________________________________ Fax    : ( ____ ) ______ – ___________
City: ______________________________ State: _________________________ Zip code: __________
Please list all the medications you are currently taking, including Name, Strength and Times per day.
Please indicate if you have never taken this medication before by placing an ‘N’ before the name of the medication.
1. _____________________________________  2. _____________________________________
3. _____________________________________  4. _____________________________________
5. _____________________________________  6. _____________________________________
7. _____________________________________  8. _____________________________________
9. _____________________________________ 10. _____________________________________

 

Patient Medical History (Optional – filled out by the Patient)

1 – Generic medications can be used if available?  Yes _____ No _____.
2 – Child resistent containers are mandatory in Manitoba where appropriate.
If you do not want them please check the box at the right.
– When would you like a pharmacist to call you to discuss your medication?

Signature: _____________________________  Date: _____________________________

Mail: Thrifty Meds Now – 408 Main Street – Box 490 – Manitou, Manitoba, Canada, R0G 1G0
Phone: Toll free 1-866-999-7928  Fax:Toll free 1-866-292-7217

For office Use Only  –  Counselling completed.  Date: _________________