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Administrative Questionnaire Index

Looking to optimize your internal procedures? Use our administrative-type questionnaires!

Updated this week

💡 All questionnaires include:

  • Date of birth

  • Gender

  • Allergies

  • Pregnancy and breastfeeding

  • Height and weight

  • Consent for remote care

Consultation module

File Opening

Goals: Collect the essential information required to create a new patient file.

Content and Tips

Content

  • Basic information: Address.

  • Lifestyle habits: Smoking status.

  • Photo of insurance card

  • Medication use: Prescription medications filled at other pharmacies, over-the-counter (OTC) products, and natural health products (NHPs).

  • Prescriber details

  • Desire for non-secure caps vials

  • Consents: Sharing information with a third party and with other healthcare providers.

Patient’s File Update

Goals: Collect the essential information needed to update a patient’s file.

Content and Tips

Content

  • Lifestyle habits: Smoking status, use of alcohol, drugs, cannabis, and coffee.

  • Photo of insurance card

  • Medication use: Prescription medications filled at other pharmacies, over-the-counter (OTC) products, and natural health products (NHPs).

  • Prescriber details

  • Consents: Sharing information with a third party and with other healthcare providers.

Complete Data Collection

Goals: Collect a complete set of patient information.

Content and Tips

Content

  • Basic information: Language, ethnic background, preference for generic vs. brand-name medications.

  • Lifestyle habits: Smoking status, use of alcohol, drugs, cannabis, coffee, and grapefruit.

  • Photo of insurance card

  • Medication use: Prescription medications filled at other pharmacies, over-the-counter (OTC) products, and natural health products (NHPs).

  • Prescriber details

  • Desire for non-secure caps vials

  • Medical conditions: Physical limitations, chronic conditions, family medical history, and surgical history.

  • Consents: Sharing information with a third party and with other healthcare providers.

Prescription/Record Transfer Request

Goals: Facilitate the process of transferring a patient file between pharmacies.

Content and Tips

Content

  • Transfer details: Pharmacy phone number, full or partial transfer, list of medications to be transferred, and request for a transfer for another family member (including their information) and insurance transfer.

  • Need for medication preparation

  • Lifestyle habits: Smoking status.

  • Consents: Sharing information with a third party and with other healthcare providers.

Tips

If a patient requests a transfer, send them the Prescription/Record Transfer Request questionnaire. Once completed, the pharmacy assistant opens the questionnaire, selects the “Prescription Transfer Form” intervention, fills in the details, prints the Interventions section, and faxes it to the other pharmacy.

Prescription Renewal

Goals: Facilitate data collection for renewing prescriptions.

Content and Tips

Content

  • Required information for renewal: Recent changes in the patient’s health condition, treatment effectiveness, additional assessments for hypertension and diabetes, presence of side effects, adherence assessment, and number of remaining doses at home.

  • Medical follow-up: Prescriber details, upcoming medical appointments, and planned blood test.

  • Need for medication preparation

Tips

If the patient has no refills left at intake

Send the Prescription Renewal questionnaire immediately. While the patient completes it:

  • Renew the treatment for 3 months.

  • Process the billing.

  • Prepare the medication.

Result: The pharmacist receives the prescription, billing, prepared medication, and the patient’s responses all at once, enabling quick review and adjustments as needed.

If only one refill remains in the file

When dispensing the last refill, inform the patient that you will send them a questionnaire in preparation for the next extension, then:

  • Place the renewed medication on hold in the file.

Result: The renewal will be done proactively, and a refill will be available at the next visit.

Prescription Renewal with File Update

Goals: Collect information for a treatment renewal and update the patient's file simultaneously.

Content and Tips

Content

All content of the Prescription Renewal questionnaire

  • Lifestyle habits: Smoking status.

  • Consents: Sharing information with a third party and with other healthcare providers.

New Medication Prescription

Goals: Collect essential information for issuing a new prescription.

Content and Tips

Content

  • Lifestyle habits: Smoking status.

  • Prescription details: Prescriber’s name, prescription purpose, medication history, preference for generic vs. brand-name, samples received from prescriber, photo of the prescription.

  • Medication use: Prescription medications filled at other pharmacies.

  • Insurance update

Tips

This questionnaire is useful for any new prescription, especially if the patient has the prescription in hand. The form allows patients to upload a photo of their prescription, which can help expedite the preparation of their medication before they arrive.

Consent Form

Goals: Ensure all required consents are properly obtained.

Content and Tips

Content

  • Legal authorization for a representative to provide consent on the patient’s behalf.

  • Consents:

    • Sharing information with third parties and healthcare providers.

    • Privacy policy compliance.

    • Remote care.

Tips

Consent is already included in the following questionnaires: File Opening, Patient's File Update, Complete Data Collection, and Prescription/Record Transfer Request.
Check whether one of those forms is more suitable before sending the standalone Consent Form.

The Consent Form is also available in the Follow-up module, allowing you to schedule recurring reminders for consent if needed.

Hospital Discharge

Goals: Ensure a smooth care transition after hospital discharge.

Content and Tips

Content

  • Hospitalization details: Date, location, reason for hospitalization, and name of the attending physician.

  • Main caregiver: Primary contact for any questions or follow-up after discharge.

  • Medication information: Last dose taken, medications provided by the hospital, need for blister packaging, and need for medication delivery.

Medication Order for Long-Term Travel

Goals: Facilitate medication preparation before a long trip.

Content and Tips

Content

  • Travel details: Duration, departure date, and expected pickup date for the medications.

  • Medication needs: List of medications to prepare.

Pharmacological Profile Request

Goals: Collect all the necessary information for a profile request.

Content and Tips

Content

Request details: Requestor’s name, patient's authorization, institution name, fax number, phone number, and urgency of the request.

Confidential

Goals: Provide a discreet way for patients to communicate health concerns.

Content and Tips

Content

Need assessment: Known health concern, new symptoms, or medication-related question.

Tips

If a patient prefers not to share their chief complaint at intake, offer them this option:

“No problem, I can send you a few confidential questions. Only the pharmacist will see your answers, which will help them better prepare for your consultation and provide appropriate advice.”

Follow-Up module

Expensive Product Order

Goals: Facilitate the ordering process for high-cost medications.

Content and Tips

Content

  • Order details: Medication needed, recent health changes.

  • Depending on the customization:

    • Weight update

    • Delivery: Delivery requirements, address, and preferred date.

Tips

This follow-up replaces monthly assistant phone calls with secure messaging, saving time while maintaining excellent service. Best practices include:

  • Recurring scheduling: Schedule the follow-up to be sent at regular intervals (e.g., every 28 days).

  • First follow-up: Send the first follow-up one week before the expected refill date. This gives time to order the product or manage a late response from the patient.

  • Questionnaire customization: Specify the medication type, whether a weight check is needed, and if delivery should be offered.

  • Personalized message to the patient: Indicate the medication name in the personalized message.

Enrollment in PAR (Pre-Authorized Refills)

Goals: Assess ongoing treatment effectiveness and patient preferences for the PAR service.

Content and Tips

Content

  • PAR service consent

  • Therapy monitoring: Effectiveness, side effects, and adherence.

  • Depending on the customization: Duration of service requested (number of months).

Tips

Beneficial for patients not yet on PAR to assess eligibility.

Pre-Authorized Refills (PAR)

Goals: Confirm patient needs and preferences for ongoing pre-authorized refills.

Content and Tips

Content

  • Medication needs: Regular and as-needed medications.

  • Depending on the customization:

    • Delivery: Delivery requirements, address, and preferred date.

Tips

This follow-up replaces monthly assistant phone calls with secure messaging, saving time while maintaining excellent service. Best practices include:

  • Recurring scheduling: Schedule the follow-up to be sent at regular intervals (e.g., every 28 days).

  • First follow-up: Send the first follow-up 3–5 days before the expected refill date. This gives time to order the product or manage a late response from the patient.

  • Questionnaire customization: Indicate whether delivery should be offered.

  • Personalized message to the patient: Indicate the medication names in the personalized message.

Pill Blister Pack Justification and Blister Pack Follow-Up

Goals: Determine eligibility for code P according to rules 24 and 25, and ensure ongoing patient follow-up.

Content and Tips

Content

Depending on the customization:

  • Blister Pack Follow-up, including a summary update of the record

    • Lifestyle habits: Smoking status, alcohol, drug, cannabis, coffee, and grapefruit consumption.

    • Health status: Recent changes in the patient’s health condition.

    • Medication use: Prescription medications filled at other pharmacies.

    • Therapy monitoring: Effectiveness, side effects, and adherence.

  • Blister Pack Justification to determine eligibility for code P

    • Coordination: Patient’s care setting and health care provider details.

    • Blister pack justification: Context requiring the use of a blister pack, barriers to self-managing medication, and current ability to manage medications.

  • Consent to share information with a Central Fill pharmacy

Tips

Set a 365-day recurrence to automatically re-assess eligibility each year.

Customize the follow-up based on your needs:

  • It can be used to assess eligibility and/or provide ongoing patient monitoring.

  • Activate the consent request if you are working with a Central Fill.

Vaccine Dose Reminder

Goals: Remind patients to book or confirm a vaccination appointment.

Content and Tips

Content

  • Vaccines: Shingles, Influenza, Hepatitis A and B, COVID-19, Meningococcal, Varicella, HPV, Tetanus, Pertussis, Rabies.

  • Appointment booking method:

    • Offer to have the pharmacy call the patient.

    • Patient must call.

    • Clic Santé.

    • Pharmacy's website.

    • Confirm attendance – Appointment already booked: Confirming attendance for already scheduled appointments.

  • Based on customization: Post-injection monitoring.

Tips

When customizing the follow-up:

  • To invite the patient to schedule an appointment, select the appropriate method in the Appointment Booking Method section.

  • To confirm an already scheduled appointment, select the "Confirm attendance – Appointment already booked" option.

  • If you'd like the patient to schedule their appointment online, add a personalized message or question for the patient along with the link to the appointment booking website.

Blood Test Reminder

Goals: Remind patients to book or confirm their blood test appointment.

Content and Tips

Content

Blood test done outside the pharmacy.

  • Confirm if a blood test has been taken or is scheduled.

Blood test done in the pharmacy.

  • "Schedule a blood test at the pharmacy", or "Remind the patient that a blood test is scheduled."

    • Photo of the requisition form, history of vasovagal reactions, and use of anticoagulants.

  • Appointment booking method:

    • Offer for the pharmacy to call the patient

    • Ask the patient to call the pharmacy.

    • Ask the patient to book an appointment online.

Tips

For blood tests performed outside the pharmacy, send the questionnaire selecting:

  • Type of blood test reminder: Confirm if a blood test has been taken or is scheduled.

  • Appointment method: Does not apply - Only confirm if a blood test is done or scheduled.

This replaces the call to the patient when no lab result is yet available, allowing you to determine if and when the appointment was scheduled.

If the blood test is performed in the pharmacy, the questionnaire can also be used to schedule the appointment or remind the patient that a blood test is scheduled for a previously set date.

Medication Injection Reminder

Goals: Remind patients to refill their injectable treatment or confirm an upcoming appointment.

Content and Tips

Content

  • Medications: Depo-Provera, Abilify Maintena, Prolia, B12, Ozempic, and other injectable medications.

  • Appointment booking:

    • Offer for the pharmacy to call the patient

    • Ask the patient to call the pharmacy.

    • Ask the patient to book an appointment online.

  • Therapy monitoring: Side effects depending on the medication.

Tips

  • Recurring scheduling: Schedule follow-ups according to injection frequency (e.g. every six months for Prolia).

  • First follow-up: Send the first follow-up one week before the expected refill date. This gives time to order the product or manage a late response from the patient.

  • If you'd like the patient to schedule their appointment online, add a personalized message or question for the patient along with the link to the appointment booking website.

Expired Products to Refill

Goals: Remind the patient to refill an expired product.

Content and Tips

Content

  • Medications: Nitroglycerin, EpiPen, Baqsimi, Naloxone, and Aerochamber.

  • Coordination: Refill needs and quantity to be refilled.

  • Based on customization:

    • Delivery: Delivery requirements, address, and preferred date.

Tips

Send the questionnaire on or shortly before the expiry date to remind the patient to refill in time.

Communications to Patient

Goals: Streamline key communications with patients.

Content and Tips

Content

Types of communications for the patient:

  • Notify that the patient's order is ready.

  • Notify the patient that they missed the delivery of their order: Reschedule the delivery date.

  • Laboratory Results Received - Everything is Normal.

  • Notify the patient that a medication is missing/needs to be ordered.

  • Notify the patient that they have not yet picked up their order at the pharmacy: Confirm whether it should be canceled or not.

Tips

If you wish to communicate a different type of information to the patient, don’t select any option in the follow-up customization.

Then, send a personalized message with the relevant details.

If you are expecting a response from the patient, add a question to help facilitate the exchange.

Reception of an Ordered Product/Medication

Goals: Streamline communication with the patient when a product or owed medication is received.

Content and Tips

Content

Type de réception:

  • Reception of an ordered medication or product.

  • Reception of a medication or product owed to the patient.

Based on customization:

  • Delivery: Delivery requirements, address, and preferred date.

Reception of a Prescription via Fax

Goals: Streamline communication with the patient when a faxed prescription is received.

Content and Tips

Content

Based on customization:

  • Types of Prescription Renewals:

    • Regular medications – no changes to treatment.

    • Includes dosage adjustments: Requests justification for the change in medication dosage.

    • Includes one or more new medications: Requests reason for new medication initiation.

  • Prescription Filling Request:

    • Ask if they want their prescription filled: Specifies which medications to prepare.

    • Do not ask if they want their prescription filled: Informs the patient that their medications will be kept on file.

  • Delivery: Delivery requirements, address, and preferred date.

Tips

Use this questionnaire as an alternative to calling patients to inform them that a prescription was received by fax.

  • To simply inform the patient, select
    ​“Do not ask if they want their prescription filled” in the Prescription Filling Request section.

  • To offer medication preparation, select
    ​“Ask if they want their prescription filled.”

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