Self-Assessment Test

If you are over 65 years old and check YES to 4 or more of these questions you may need an appointment...

You should consider making an appointment with a senior care pharmacist to determine what steps can be taken to decrease your risks. While these risk factors are not a definitive list, they have been found to correlate with the risk of medication-related problems.

• 1. Are you currently taking five or more medications?
  Yes

  No

• 2. Are you taking 12 or more doses of medications per day?
  Yes

  No

• 3. Are you taking any of the following medications?
  Yes

  No

• a. Carbamazepine (Tegretol)

  YES NO
  b. Lithium (Eskalith)

  YES NO
  c. Phenytoin (Dilantin)

  YES NO
  d. Quinidine (Quinidex)

  YES NO
  e. Warfarin (Coumadin)

  YES NO
  f. Digoxin (Lanoxin)

  YES NO
  g. Phenobarbital

  YES NO
  h. Procainamide (Procanabid, Pronestyl)

  YES NO
  I. Theophyllin (TheoDur, Theo-24, Slow-Bid, Uniphil)

  YES NO
  j. Beta Blockers (Inderal, Lopressor, Toprol XL, etc)

  YES NO
  k. Alpha Blockers (Cardura, Catapres, Hytrin, Flomax, etc)

  YES NO
  l. Levothyroid (Synthroid, etc)

  YES NO
• m. Darvocet N 100

  YES NO
  n. Statin drugs (Zocor, Pravacor, Lopid, etc)

  YES NO
  o. Metformin (Glucophage)

  YES NO
  p. Glucotrol, Amaryl, Diabeta

  YES NO
  q. Hydrochlorthiazide

  YES NO
  r. Nitrofuranton (Macrodantin)

  YES NO
  s. NSAIDS (Motrin, Aleve, etc)

  YES NO
  t. Antihistamines (Benadryl, Antivert, Tylenol PM, Sleep-Ezz, Dramamine, etc)

  YES NO
  u. Cimetidine (Tagamet)

  YES NO
  v. Ketoconazole (all oral antifungal drugs)

  YES NO

• 4. Do you take medications for three or more medical problems?
  Yes

  No

• 5. Have your medications - or the instructions for taking them - changed four or more times this past year?
  Yes

  No

• 6. Does more than one physician prescribe medications for you on a regular basis?
  Yes

  No

• 7. Are your prescriptions filled by more than one pharmacy?
  Yes

  No

• 8. Does someone else bring your medications to your home (spouse, friend, neighbor, delivery person, etc.)?
  Yes

  No

• 9. Do you find it difficult to follow your medication regimen or sometimes do you choose not to?
  Yes

  No

• 10. Are you taking any medication(s) without knowing exactly why it's been prescribed for you?
  Yes

  No

If you answered YES to 4 or more of these questions, complete the following information on the ASSESSMENT FORMS section and submit it for a complete evaluation and recommendations.

MedicationXpert - Griffin,GA
30224 - (770) 412-7666