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MMP Monthly Visit Form
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MTR
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Patient Name
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Language Barrier
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Type of visit
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Medication Start Date
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Medication Delivery Date
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Packaging
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Medication Allergies & Adverse Reaction
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Recent hospitalizations or doctor visits
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Any upcoming appointments?
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If yes, when is next appointment.
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PMH
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Does the patient need OTCs/bulk items?
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OTCs/bulks needed
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Does Patient need any refills
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Refills needed
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Patient Questions
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Adherence Measures
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How do you remember to take your meds?
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If other, please specify
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Have you missed any days of meds?
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If so how often?
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Is Parata/Multi Dose helping you remember?
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If no, indicate why/want to change?
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Additional Comments/Notes
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Social Determinants/Barriers
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Challenges taking the meds?
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Challenges related to home/transportation?
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Medication Related Problems:
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Diabetic Patient
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Does the patient test blood sugar at home?
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Are the readings consistent or changing?
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Average blood glucose readings
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Last time A1c was checked
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Recommend getting glucose testing supplies
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Patient Notes/Comments
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Hypertension
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Does the patient check their BP at home?
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Are the readings consistent or changing?
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Typical BP reading
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Recommended getting BP machine
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Patient Notes/Comments
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Heart Failure
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Any weight changes overnight or past week?
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If yes to weight change, how much?
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If Yes, advise to see clinic
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Is patient maintaining a low-sodium diet?
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If on diuretics, is there swelling in lower extremities?
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If yes, is it worse, consistent or better?
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Patient Notes/Comments
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Sleep
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How many hours of sleep?
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Is the patient receiving quality sleep?
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Any disrupting factors?
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Patient Notes/Comments
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For RPh to review
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Needs Therapy
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Recommendations
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Outcome
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Other Recommendation
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Unnecessary therapy
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Recommendations
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Outcome
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Other Recommendations
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