Name:

UČO:

Date:

Patient´s Profile


Age (year of birth)

Sex

Weight

Height

BMI



Reason of the visit


History of present illness


Personal History


Assesment and lab results


Diagnosis


Chronic pharmacotherapy

Name of drugs, dosage, reasons for discontinuation


Current pharmacotherapy

Name of drugs, dosage, reasons  for use


Adverse effect


Drug interactions


Proposed changes in pharmacotherapy,

reasons


Plan for next visit, date of next visit


Plan for next 3 months


Assesment