HbL Medication-Risk Questionnaire
Are You At Risk of Having a Medication-Related Problem?
Answer the following 10 questions to find out
1.
 Do you currently take 5 or more medications? Yes No
2.
 Do you take 12 or more medication doses each day? Yes No
3.
 Do you take any of the following medications:
  • Carbamazepine
  • Lithium
  • Phenytoin
  • Quinidine
  • Warfarin
  • Digoxin
  • Phenobarbital
  • Procainamide
  • Theophylline
Yes No
4.
 Does more than one physician prescribe medications for you
on a regular basis?		 Yes No
5.
 Are you currently taking medications for three or
more medical problems?		 Yes No
6.
 Do you get prescriptions filled at more than one pharmacy? Yes No
7.
 Does someone else bring any of your medications to
your home for you?		 Yes No
8.
 Is it difficult for you to follow your medication regimen or do
you sometimes choose not to?		 Yes No
9.
 Have your medications or the instructions on how to take them
been changed four or more times in the past year?		 Yes No
10.
 Of all your medications, is there any particular medicine
for which you do not know the reason for taking it?		 Yes No
If you marked 2 or more of the Yes buttons, it could indicate that you are at a higher risk of having problems caused by your medications.

It is important to ask your health care professional or pharmacy expert to review your medications to prevent or correct medication-related problems.
Click here to find a senior care pharmacy expert in your geographical region.
Click here to submit a drug information question to Dr. Levy, PharmD.
Click here to download this page in Adobe PDF format.
Click here to download the survey in Adobe PDF format.