Patient Name: ________________________________ Date of Birth: _______________ Date: _______________
Important: Please list ALL medications including prescriptions, over-the-counter drugs, vitamins, herbal supplements, and patches. Include the dose and how often you take each one.
Current Medications
Medication Name
Dose (mg)
Frequency
Prescribing Doctor
Reason / Condition
Over-the-Counter Medications & Supplements
Name / Brand
Dose
Frequency
Reason for Use
Drug Allergies & Adverse Reactions
List any medications that have caused an allergic reaction or serious side effect. Include the reaction that occurred.