Pharmacist Consultation Form

Patient Information:

Full Name

Date of Birth

Gender

Male

Female

Address

Phone Number:

Medical History: Yes/No. If yes, please explain

Do you have any known allergies? If yes, please specify

List any chronic medical conditions you have

Are you currently taking any prescription medications? If yes, please provide details (medication name, dosage, and frequency)

Do you take any over-the-counter medications, herbal supplements, or vitamins? If yes, please provide details

Have you recently undergone any surgeries or medical procedures? If yes, please provide details:

Do you Have any current Symptoms/Condition. Y/N.

Yes

Describe your symptoms/condition briefly:

When did the symptoms/condition start?

Have you tried any medications or remedies for your symptoms/condition? If yes, please provide details:

Are you pregnant or breastfeeding? If yes, please provide details:

Do you have any specific concerns or questions regarding your symptoms/condition or medication usage?

Is there any other relevant medical information that you would like to share?

Disclaimer: Please note that this form is for informational purposes only and does not establish a pharmacist-patient relationship. The information provided will be treated with confidentiality and used solely for the purpose of providing consultation services. Consult a healthcare professional for a definitive diagnosis and treatment plan.