Medication Safety Questionnaire Form

If an authorized physician wants to prescribe a medication to be used by a patient, he/she has to complete the Medication Safety Questionnaire Form.

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Medication Safety Questionnaire 
Name 
Brand:_______________ 
Generic:_____________ 
Dose (e.g., mg) and form (e.g., tabs) When to take each dose? For how long? 
1. What is the medication supposed to do? 
2. How long before I will know it is working or not working? 
3. What about serum (blood) levels? Other laboratory work? How often? Where? 
Standing order? 
4. If the individual misses a dose, what should I do? 
INTERACTIONS? 
5. Should this medication be taken with food? □ Yes □ No 
At least one hour before or two hours after a meal? □ Yes □ No 
6. Are there any foods, supplements (such as, herbs, vitamins, minerals), drinks 
(alcoholic, for example), or activities that should be avoided while taking this 
medication? 
□ Yes (Which ones?) 
____________________________________________________ 
□ No 
7. Are there any other prescription or over-the-counter medications that should be 
avoided? 
□ Yes (Which ones?) 
____________________________________________________ 
□ No 
SIDE EFFECTS? IF SO, RESPONSE? 
8. What are common side effects? 
9. If there are any side effects, what should I do? 
10. If the drug is being prescribed for a long period of time, are there any long-term 
effects?