Medication list

Patient
First Name
Last Name
Date of Birth
Pharmacy Name
 Location
Phone #
Allergies
Do you have drug allergies? NO:      YES:

List all medication allergies and reactions including latex:

Medication/Reaction Medication/Reaction
Medications
Currently on medications? NO:    Yes:

List all medications including OTC drugs & herbal supplements:

Medication Name
(RN check if taken today)		 Dose/FrequencyUnknown Indication (Reason)

Blood Thinnners (Including Aspirin)

Blood Thinners: Dose/FrequencyUnknown Indication (Reason)

The above is a complete and accurate medication list to the best of my knowledge. It includes over the counter and herbal supplements, as well as regular and occasionally used prescription drugs. Your physician will be resuming the start of your medication on the information provided by you, including the name of the medications, dosages and frequency.
I agree: