Name *
Please circle either the number '1' for an affirmative response, or the number ‘0’ for a negative response, to the corresponding questions below.
Special populations such as these are inherently more likely to be at risk for medication-related problems.
Multiple providers increase the risk for medication-related problems secondary to a lack of efficient communication amongst providers.
e.g. medications for conditions for high blood pressure, diabetes, mood/mental health conditions, chronic infections, Parkinson’s, ADHD, Asthma, and COPD.
OTCs, supplements, and herbals have the potential to interact with prescription medications since they are metabolized and cleared from the body through the same mechanisms as prescription medications.
Combinations of medications can increase the risk for medication-related problems.
Changes in memory can sometimes be associated with medication-related problems.
Changes in mood or behavior can sometimes be associated with medication-related problems.
Filling prescriptions at more than one pharmacy can increase the likelihood of medication-related problems.
Some medications are associated with a higher risk of medication-related problems like unwanted side effects and adverse reactions and all should be reviewed for safety. For example, some individuals may experience severe muscle pain and stiffness while taking a statin for high cholesterol.
Individuals who are unable to take medications as prescribed or rely on others increase their risk of medication-related problems.
Individuals who have been recently hospitalized are at increased risk for medication errors.
After answering all of the above questions, please add the points together from all the responses to obtain a total score, and then circle the level of risk that the score corresponds to on the next page.

If the total score falls into the Medium or high risk categories, please complete the form below.

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Referral for Comprehensive Medication Review

With the permission of the individual who would benefit from having their medications reviewed, please return completed document via fax (818) 514-2027 or scan and email at

Name (last, first) of individual: *
Name (last, first) of individual:

Please feel free to contact us with any questions (818) 514-2183