Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
We will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, weneed to know if you have any medication allergies or medical conditions. We also need to know what prescription andnonprescription medications you take regularly.
Your privacy is important to us. We comply with federal privacy regulations and will protect this information.
Follow the steps listed below.
Step 1:
Verify and complete information in SECTION 1.
Step 2: Complete all sections below using blue or black ink. Please print.
Step 3: Return the completed questionnaire in the self-addressed envelope with your mail-order form or refills. If you
do not have a preaddressed envelope, please return the questionnaire to:
Medco Health Solutions, Inc.
4865 Dixie HighwayFairfield, OH 45014Attn: HMQ SECTION 1: Patient information
Patient member number:(Located on your ID card.) SECTION 2: Your medication allergies
Fill in the oval completely if you have had an allergy or serious reaction to any of these medications:
Aspirin and salicylates (for example: ZORprin®, Trilisate®)Codeine (for example: Tylenol® #3)Erythromycin, Biaxin®, Zithromax®Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®)Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin) Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX)Tetracycline antibiotics If you have an allergy to a medication that is not listed above, print the name of that medication in the space below. Example: morphineother: SECTION 3: Your medical conditions
Has your doctor ever told you that you have any of the conditions listed below? If so, fill the oval completely next to all that apply.
Hemophilia and hemophilia-like conditions Bladder control problem (urinary incontinence) Enlarged prostate (benign prostatic hyperplasia, Gastric reflux, heartburn, or esophagitis (GERD) If you have a medical condition that is not listed above, print the name of that medical condition in thespace below. Example: breast cancer SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
If you take a nonprescription medication that is not listed above, print the name of that medication inthe space below.
SECTION 5: Patient prescription medications*
Please list the prescription medications you are currently taking in the space below. *Information
can be found on the prescription labels. If none, please check here. [ ] NONE
Did you complete both sides?
Thank you very much.

Source: http://flumc.brickriver.com/files/oPage_Manager_Files/PMMAE7MM_uhc-_Mail_order_questionnaire.pdf


GOJO Industries, Inc. One GOJO Plaza, Suite 500P.O. Box 991Akron, OH 44309-0991Tel: 1-330-255-6000Toll-free: 1-800-321-9647Fax: 1-800-FAX-GOJOwww.GOJO.com Good Hand Hygiene: One of the Best Defenses Against MRSA Major world health organizations, including the Centers for Disease Control and Prevention (CDC) and the Public Health Agency of Canada recommend practicing good hand hygiene, which

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