Demographic
Age
Sex M/F
Race W/B/other
Comments:
Disease
CVA: L/R	CHF/atrial fibrillation
Dehydration	CAD/hypertension
Dementia: mild/moderate/severe	IDDM/NIDDM
Depression	UTI/pneum
Psychosis	COPD/asthma
Parkinson’s/MS	GI
Thyroid	Hematologic
Renal/BPH	Fracture
Cancer	OA/RA/other
	Skin
Medications
Diuretic	Antidiabetic
Antihypertensive	Thyroxine
Antipsychotic	Antiulcer
Antidepressant	Platelet inhibitor
Steroid	Antiseizure
Antianginal	Antiparkinsonian
Laxative	Narcotic
Antibiotic	Benzodiazepine
	Total medications
Laboratory Tests
BUN
Creatinine
CrCl
Body weight
Function
Weight loss 1 mo 6 mo
Visual loss
Hearing loss
Incontinence: urinary/bowel
Dysphagia
Constipation
Pain: mild/moderate/severe
If ADR:
Days to ADR
Which ADR?
Action taken:
Recurrence?

ADR = adverse drug reaction; M = male; F = female; W = white; B = black; CVA = cerebrovascular accident; L = left; R = right; MS = multiple sclerosis; BPH = benign prostatic hypertrophy; CHF = congestive heart failure; CAD = coronary artery disease; IDDM = insulin-dependent diabetes mellitus; NIDDM = non–insulin-dependent diabetes mellitus; UTI = urinary tract infection; pneum = pneumonia; COPD = chronic obstructive pulmonary disease; GI = gastrointestinal; OA = osteoarthritis; RA = rheumatoid arthritis; BUN = blood urea nitrogen; CrCl = creatinine clearance.