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DSM Experience

Non-Prescription Experience

Community Clinical Clerkship Rotation

OTC Mini-Case Presentation

Student Name

Rotation Site

Date ___/___/___

 Patient Information:

¨Male ¨ Female ¨ (Pregnant ¨ Yes ¨ No)  Race ¨ Caucasian ¨ African American ¨ Other

Date of Birth ___/ ___/___     Telephone:        -              

 Symptoms of Current Complaint

History of Present Illness

Past Medical History

Drug Allergies

 Previous treatments used for current complaint and effects experienced :

 Unrelated Current/ Past Drug History:

Physical assessment/ General observations 

 Temperature __F⁰                          Blood Pressure _____/_____mmHg

 Therapy plan: Include any non-drug recommendations

 Patient education: 

Drug information: (if OTC drug was recommended)

 Follow up:

 Patient questions: