SOUTHWEST CARDIOVASCULAR ASSOCIATES
Charles MT Jost, MD
140 South Power Road
Mesa, Arizona 85206-5297
480-945-4343 phone
480-945-4350 fax
MEDICATION LIST
PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS FOR EACH AND EVERY OFFICE VISIT.
*I understand that Dr Jost relies on the medication information I provide to him for my care, and that any medication misinformation can result in hospitalization or death. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete.
*Type your Name here*
First Name Middle Name Last Name Suffix (Jr, Sr, III, ect)
Patient Gender*
Patient Birth Date*
Month Day Year
Patient E-Mail*

Confirmation Email Confirm E-mail
Patient Phone Number*
Area Code Phone Number
Patient Drug/Medication Allergies & Allergic Reactions
Allergic to Mold/Pollen/Dust?*
Yes No Unknown
Any Drug/Medication Allergies?*
Yes No Unknown
List Drug/Medication Allergies & Reactions:
Name of Medication / Allergic Reaction 0/300
Patient Medications
Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.
Please List All Medications
Medication Name Dosage Amount #Taken Daily Ordering Doctor Start Date
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Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage:*
Yes, I Smoke Daily Yes, Sometimes I Smoke No, I Quit Smoking No, I Never Smoked
Date I Quit Smoking:*
Month Day Year
# Cigarettes per day?*
Alcohol Consumption*
I don't drink 1-4 drinks/month 1-2 drinks/day 3-4 drinks/day 5+ drinks/day
Caffeine Consumption*
I don't use caffeine 1-4 cups/month 1-2 cups/day 3-4 cups/day 5+ cups/day
Today's Date*
Month Day Year
Type Security Code Below*
Should be Empty:

	Medication Name	Dosage Amount	#Taken Daily	Ordering Doctor	Start Date
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MEDICATION LIST

Patient Drug/Medication Allergies & Allergic Reactions

Patient Medications

Patient Tobacco/Alcohol/Caffeine Usage