Patient Information Sheet--Medication List

Please list ALL PRESCRIPTION MEDICATIONS and OVER-THE-COUNTER MEDICATIONS you have taken in the past month including cold remedies, natural remedies, sleeping pills, weight loss pills and vitamins
(be sure to list if you DRINK or SMOKE and specify how much of each you use):

Date: _____________ Name: ____________________________________________
Medication Name Pill/Drug Size
(ex. "5 mg")		 How Often
(ex. "3x a day"--write "prn" also if only as needed)		 Average Taken Each Day
(ex. "1 every 3 days")		 Reason
(ex. "high blood pressure", "dizziness")
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
Alcohol?
Cigarettes?
Cold Remedies?
Natural Remedies?
Pain Medication?
Sleeping Pills?
Vitamins?
Weight Loss Pills?
Other?
Other?
Other?
Other?
Other?