Brief Medication History Transfer Form
Please complete this form so that we may serve you better. Please complete one form for each family member.
Full Name
Date of Birth
/
Month
/
Day
Year
Date
Address
Primary Phone Number
Is this a
Home Phone
Cell Phone
Work Phone
Allergies (Medications, food, dyes, etc.)
Insurance Carrier and Cardholder ID (SSN for Auxiant)
Tribal Member?
Yes
No
Ho-Chunk Employee?
Yes
No
What department?
Text message notification when prescription is ready
Yes
No
Current Pharmacy Information:
What is your current pharmacy information (if you have more than one, please list both)
Pharmacy name
Address
Phone number
Add another Pharmacy?
Yes
No
Pharmacy name
Address
Phone number
Do you get medications from a mail order pharmacy or the internet?
Yes
No
If yes, which one?
Please Select
Mail order pharmacy
Internet
Both
How would you like to obtain your prescriptions?
Pick up at House of Wellness Pharmacy in Baraboo
Pick up at Health Care Center Pharmacy in Black River Falls
Mail (if you are a non-tribal member, please contact the pharmacy to provide payment information for copays)
Does anyone help you with your medications (family, nurse, etc)?
Yes
No
If yes, what is their contact information?
Who is your primary doctor?
Is it ok if I contact your helper or primary doctor if I need more information?
Yes
No
Past Medical History:
Asthma
Heart attack
Irregular heartbeat (atrial fibrillation)
Insomnia (difficulty sleeping)
Anxiety
GERD (acid reflux)
COPD
Ulcers (stomach/intestine)
Diabetes
Thyroid disease
Depression
Stroke
High cholesterol
Cancer
High blood pressure
Other
Past Surgical History (angioplasty or stent, bypass surgery, pacemaker, etc)
Current Medications (Include OTCs, herbals, supplements, and meds from mail order, internet, and friends)
(Please complete to the best of your knowledge.)
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here?
Yes
No
Fill now?
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer now:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer now:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Dosage
Reason for Taking
Directions
Doctor
Current Pharmacy
Transfer here:
Yes
No
Fill now:
Yes
No
Any Notes to the Pharmacy?
Submit
Should be Empty: