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Administrative Questionnaire Index

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

Updated over 2 months ago

💡 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 patient file.

Content and Tips

Content

  • Basic information: Address.

  • Lifestyle habits: Smoking status.

  • Prescription Drug Insurance card photo

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

  • Prescriber details

  • Preference for non-child-resistant (non-secure) vial caps

  • Consents: Information sharing with third parties and healthcare providers.

Patient’s File Update

Goals: Gather the key details required to update the patient’s record.

Content and Tips

Content

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

  • Prescription Drug Insurance card photo

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

  • Prescriber details

  • Consents: Information sharing with third parties and healthcare providers.

Complete Data Collection

Goals: Collect a complete set of patient information.

Content and Tips

Content

  • General information: Language, ethnic background, and preference for generic versus brand-name medications.

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

  • Prescription Drug Insurance card photo

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

  • Prescriber details

  • Preference for non-child-resistant (non-secure) vial caps

  • Medical conditions: Physical limitations, chronic illnesses, family medical history, and past surgeries.

  • Consents: Information sharing with third parties and healthcare providers.

Prescription/Record Transfer Request

Goals: Simplify the process of transferring patient files between pharmacies.

Content and Tips

Content

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

  • Need for medication preparation

  • Lifestyle habits: Smoking status.

  • Consents: Information sharing with third parties and healthcare providers.

Tips

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

Prescription Renewal

Goals: Streamline data collection for prescription renewals.

Content and Tips

Content

  • Required information for renewal: Recent changes in the patient’s health status, medication effectiveness, additional evaluations for hypertension and diabetes, occurrence of side effects, adherence assessment, and the number of doses remaining at home.

  • Medical follow-up: Prescriber information, upcoming medical appointments, and scheduled blood tests.

  • 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 medication renewal while updating the patient’s file.

Content and Tips

Content

All content of the Prescription Renewal questionnaire

  • Lifestyle habits: Smoking status.

  • Consents: Information sharing with third parties and healthcare providers.

New Medication Prescription

Goals: Obtain key information required to process a new prescription.

Content and Tips

Content

  • Lifestyle habits: Smoking status.

  • Prescription details: Prescriber’s name, reason for prescription, medication history, preference for generic or brand-name drugs, samples provided by the prescriber, and a 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 give consent on the patient’s behalf.

  • Consents:

    • Information sharing 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: Facilitate a seamless care transition following hospital discharge.

Content and Tips

Content

  • Hospitalization details: Date, location, reason for hospitalization, and attending physician’s name.

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

  • Medication information: Last dose taken, medications supplied by the hospital, requirement 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: Gather all required information for a profile request.

Content and Tips

Content

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

Confidential

Goals: Offer patients a discreet way to share their health concerns.

Content and Tips

Content

Needs assessment: Health concerns, new symptoms, or medication-related questions.

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: Simplify the process for ordering high-cost medications.

Content and Tips

Content

  • Order details: Medication needed, recent health changes.

  • Based on customization:

    • Weight update

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

Tips

This follow-up replaces monthly assistant/technician phone calls with secure messaging, streamlining workflows while maintaining high-quality patient service. Recommended best practices include:

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

  • First follow-up: Send the first follow-up one week before the expected refill date to allow time for ordering the product or handling any delayed response from the patient.

  • Questionnaire customization: Specify the medication type, indicate whether a weight check is required, and confirm 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.

  • Based on customization: Duration of requested service (months).

Tips

Useful for assessing eligibility of patients not yet enrolled in PAR.

Pre-Authorized Refills (PAR)

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

Content and Tips

Content

  • Medication needs: Regularly taken and as-needed medications

  • Based on 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: Assess eligibility for code P based on rules 24 and 25, and ensure continuous 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 and consumption of alcohol, drugs, cannabis, coffee, and grapefruit.

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

    • Medication use: Medications prescribed and filled at other pharmacies.

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

  • Blister Pack Justification to assess eligibility for code P

    • Details: Patient Care Setting and provider information.

    • Blister pack justification: Context for using a Blister Pack, barriers to medication self-management, and current medication management ability

  • Consent to share information with a Central Fill pharmacy

Tips

Set a yearly (365-day) recurrence to automatically reassess eligibility.

Customize the follow-up based on your needs:

  • 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 schedule or confirm their 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 for the pharmacy to call the patient

    • Patient must call to book the appointment.

    • Clic Santé.

    • Pharmacy's website.

    • Confirm attendance – Appointment already booked

  • 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 upcoming appointment.

Content and Tips

Content

Blood test done outside the pharmacy

  • Confirm whether a blood test has been done 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 blood test requisition, history of vasovagal reactions, and anticoagulant use.

  • 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 medication or confirm their 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: Medication-specific side effects.

Tips

  • f yRecurring scheduling: Schedule follow-ups based on injection frequency (e.g., every six months for Prolia).

  • First follow-up: Send the first follow-up one week before the expected refill date to allow time for ordering the medication or addressing any delayed patient responses.

  • If you want the patient to book their appointment online, include a personalized message or question along with the link to the scheduling 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.

  • Refill details: Quantity and requirements.

  • Based on customization:

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

Tips

Send the questionnaire on or shortly before the expiry date to timely remind the patient to refill their medication.

Communications to Patient

Goals: Streamline key communications with patients.

Content and Tips

Content

Type of communication to patients:

  • Notify the patient that their order is ready for pickup.

  • Inform the patient that they missed their delivery and assist with rescheduling.

  • Laboratory results received – all within normal limits.

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

  • Inform the patient that their order has not yet been picked up and confirm whether to cancel it.

Tips

If you need to communicate a different type of information to the patient, do not select any options in the follow-up customization. Instead, send a personalized message with the appropriate details.
If you expect 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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