267 OPERAM: cluster randomised controlled trial - SI Structured History Taking of Medication (SHIM) Questions asked per drug on the medication list, provided by the community pharmacist Drug no.: ___________ Drug Name: _________________________________ 1. Are you using this drug as prescribed (dosage, dose frequency, dosage form)? Yes/No [Specify] 2. Are you experiencing any side effects? Yes [specify]/No 3. What is the reason for deviating (from the dosage, dose frequency, or dosage form) or not taking a drug at all? (Please tick the box that applies) Side effects Inconvenient Forgot Too expensive Difficult to swallow Unpleasant taste Other, ……. 4. Are you using any other prescription drugs that are not mentioned on this list? (view medication containers) Yes [specify]/No 5. Are you using nonprescription drugs? Yes [specify]/No 6. Are you using homeopathic drugs or herbal medicines (eg. St. Johns wort)? Yes [specify]/No 7. Are you using drugs that belong to family members or friends? Yes [specify]/ No 8. Are you using any “as needed” drugs? Yes [specify]/ No 9. Are you using drugs that are no longer prescribed? Yes [specify]/ No Questions concerning the use of medicines 10. Are you taking your medication independently? Yes/No 11. Are you using a dosage system? Yes/No 12. Are you experiencing problems taking your medication? Yes [specify]/No 13. In case of inhalation therapy: What kind of inhalation system are you using? Are you experiencing any problems using this system? 14. In case of eye drops: Are you experiencing any difficulties using the eye drops? 15. Do you ever forget to take your medication? No/Yes. If so, which medication why what do you do? 3
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