Healthcare Drug Questionnaire

HEALTHCARE DRUG QUESTIONNAIRE

This Healthcare Drug Questionnaire collects medication, substance-use, and allergy information necessary for safe clinical care. Complete all sections fully and accurately. If a question does not apply, enter "None" or "N/A." All information provided is part of the medical record.

Patient Information

Date of Birth:    Gender: Male  Female  Non-binary  Other

Insurance Information

Current Medications

List all prescription, over-the-counter, herbal supplements, and topical agents currently taken. Include dose, frequency, prescribing provider, and start date.

Allergies and Adverse Reactions

Allergic to medications: No known drug allergies

Substance Use History

Do you use tobacco products? Yes  No

Do you consume alcohol? Yes  No

Use of recreational or illicit drugs: Yes  No

Have you ever taken prescription medication not as prescribed (e.g., higher doses) or obtained prescriptions from multiple providers? Yes  No

Past Treatments for Substance Use

History of medication-assisted treatment (select all that apply):  Methadone  Buprenorphine  Naltrexone  None

Additional Clinical Questions

Are you pregnant or breastfeeding? Yes  No  Unsure

Authorization, Certification & HIPAA Acknowledgment

I certify that the information provided above is true and complete to the best of my knowledge. I understand that withholding or providing false information may adversely affect clinical decisions and medication safety. I authorize my treating provider and their authorized staff to request, receive, and review pharmacy records, prescription history, and medication-related records from pharmacies, other healthcare providers, and prescription monitoring programs as needed for diagnosis, treatment, and care coordination.

I acknowledge that I have been offered the practice's Notice of Privacy Practices and that my protected health information may be used and disclosed for treatment, payment, and healthcare operations as described in that notice. This authorization for release of medication and pharmacy records expires on the date entered below or one year from the date of signature unless revoked earlier in writing. I understand I may revoke this authorization at any time by delivering written notice to the practice, except to the extent that action has already been taken in reliance on this authorization.

By signing below I give consent for use of the information provided for clinical care and treatment planning and confirm that I have had an opportunity to ask questions regarding the collection and use of these records.

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