*click refresh to generate a new random patient.
Pharmacist Interviewer:
Patient Information (do not show pharmacist):
- Medication Reconciliation - Interview Form - CLICK HERE
Patient Information (do not show pharmacist):
Show/Hide Info (no key)
Show/Hide KEY
| Mina Mathis |
| MRN 735868 |
DOB 12/15/1958 |
Age 68 |
Gender Female |
Ethnicity African American |
Height 157.5 cm |
Weight 39.1 kg |
Creatinine 0.8 mg/dL |
| Patient Name: Mina Mathis DOB: 12/15/1958 Room: 105 |
Allergies: aspirin (severe rash, runny nose), 6 years ago | Immunization History:
|
| Community Rx Info: Walgreens Rx Insurance: Humana Pharmacy Solutions |
Social History:
|
Name |
(date/time) |
Effects |
for D,H,M |
||||||
0730 |
|||||||||
1800 |
|||||||||
0730 |
|||||||||
2100 |
|||||||||
Vitamin C |
2100 |
||||||||
| Additional Notes: CrCl = 42 mL/min based on actual body weight of 39.1 kg (ABW/IBW = 78%) | Action Key: C = Continue *Must provide reason: D = Discontinue, H = Hold, M = Modify |
| Med history obtained by (sign and print): | Date: 11-14-2026 |
| Patient Name: Mina Mathis DOB: 12/15/1958 Room: 105 |
Allergies: aspirin (severe rash, runny nose), 6 years ago | Immunization History:
|
| Community Rx Info: Walgreens Rx Insurance: Humana Pharmacy Solutions |
Social History:
|
Name |
(date/time) |
Effects |
for D,H,M |
||||||
0730 |
|||||||||
1800 |
|||||||||
0730 |
|||||||||
2100 |
|||||||||
Vitamin C |
2100 |
||||||||
| Additional Notes: | Action Key: C = Continue *Must provide reason: D = Discontinue, H = Hold, M = Modify |
| Med history obtained by (sign and print): | Date: 11-14-2026 |