Medication List

Medication List
PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS FOR EACH AND EVERY OFFICE VISIT.
Type your Name here
First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient Gender
Patient Birth Date
MonthDayYear
Patient E-Mail

Confirmation EmailConfirm E-mail
Patient Phone Number
Patient Drug/Medication Allergies & Allergic Reactions
Allergic to Mold/Pollen/Dust?
YesNoUnknown
Any Drug/Medication Allergies?
YesNoUnknown
List Drug/Medication Allergies & Reactions:
Name of Medication / Allergic Reaction0/300
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage:
Yes, I Smoke DailyYes, Sometimes I SmokeNo, I Quit SmokingNo, I Never Smoked
Date I Quit Smoking:
MonthDayYear
Date
# Cigarettes per day?
Alcohol Consumption
I don't drink1-4 drinks/month1-2 drinks/day3-4 drinks/day5+ drinks/day
Caffeine Consumption
I don't use caffeine1-4 cups/month1-2 cups/day3-4 cups/day5+ cups/day
Today's Date
MonthDayYear
Date
Type Security Code Below
Should be Empty:

Patient Drug/Medication Allergies & Allergic Reactions