Assessment for you or the one in your care

Is the patient a resident of Florida? *	Yes No
Do you currently take 5 or more medications? *	Yes No
Do you take medications for 3 or more medical problems? *	Yes No
Do you use more than one pharmacy (including mail-order)? *	Yes No
Does more than one physician regularly prescribe medications for you? *	Yes No
Is there any medication you take that you aren't sure why you are taking it? *	Yes No
Do you take any of the following medications?	Yes No
digoxin(Lanoxin, Lanoxicaps)?	Yes No
warfarin(Coumadin) ? *	Yes No
theophylline(Theo-Dur, Theo-24, Uniphyl) ? *	Yes No
phenytoin(Dilantin) ? *	Yes No
carbamazepine(Tegretol) ? *	Yes No
lithium(Eskalith) ? *	Yes No
quinidine(Quinidex) ? *	Yes No
phenobarbital ? *	Yes No
procainamide(Pronestyl, Procanabid) ? *	Yes No
65 or older? *	Yes No
Do you take 12 or more medication doses each day? *	Yes No
Have you experienced four or more changes in medications or medication instructions in the past year? *	Yes No
Does someone else bring any of your medications to your home (delivery, spouse, neighbor, friend)? *	Yes No
Is it difficult for you to follow your medication regimen or do you sometimes choose not to? *	Yes No
Take any medications differently than prescribed or not at all? *	Yes No
Addtional Comments (optional)
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