Clinicians can use this form to collect information from patients about their prior use of non-traditional or alternative care providers and medications.

Health centers can also adapt the form and/or incorporate into their EHR.

PCMH Standard 2 Element B: Clinical Data, Factor 9: List of prescription medications with date of update for 80% of patients.

PCMH Standard 3 Element D: Medication Management, Factor 3: Provides information about new prescriptions to more than 80% of patients.