Assessing for other preventive treatments and examinations includes gathering data on medications, examination and diagnostic tests, and vaccinations. See Table 2.7 for sample questions and statements, along with specific considerations. You might begin this section by asking the client, “What are the ways that are most important for you to optimize your health?” (you may have already discussed this as part of the functional health section).
It is important to ask the client about their current, past, and known future medication regime, examinations, and immunizations to form a profile of the treatment that the client has received and plans to receive. This information will tell you a lot about the client’s current health status based on the care they have and will receive.
Note: The client may refer to items that have already been discussed as part of the functional assessment or other items not yet discussed. You may need to probe with statements such as, “Tell me more,” and “How does that affect you?”
|Items||Questions and Statements||Considerations|
Name, dose, frequency, reason for taking it, when they first started taking it, and whether they take it as prescribed. This applies to both prescribed and over-the-counter medications, such as vitamins, pain relievers, homeopathic medicines, and cannabis.
Medication misuse refers to taking medications outside their prescribed purpose. It can include snorting or injecting medications or taking excessive (large) non-prescribed dosages of medications such as opioids, sedatives, stimulants, and hypnotics. Assess further if you suspect medication misuse.