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Medication & OTC Form

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Download WORD Doc: My Medication & OTC list

 

My Medication & OTC Form

 

Date:____________ Name:_________________
Primary Physician:
_________________________
Physician Telephone:      
(___) ____ - __________
Pharmacy:
_________________________________
Pharmacy Telephone:     
(___)____-_________
Allergies:
______________________________

 

Prescribed Medications (Rx)

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength
________
Qty Taken Daily ______Special Directions
____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions
____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions
____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions
____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions
____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions____________________

Drug Name __________________/Generic Name _____________
Purpose_______________________________ Strength________
Qty Taken Daily ______Special Directions
____________________


Over-The Counter  (OTC) Products:

(Vitamins, Pain Killers, Muscle Relaxers, Cold, Sinus, etc)

Name __________________/Purpose_________________
Strength_____________ How Many Are Taken Daily ______

Name __________________/Purpose_________________
Strength_____________ How Many Are Taken Daily ______

Name __________________/Purpose_________________
Strength_____________ How Many Are Taken Daily ______

Name __________________/Purpose_________________
Strength_____________ How Many Are Taken Daily ______

Name __________________/Purpose_________________
Strength_____________ How Many Are Taken Daily ______

Over the Counter Medication History 
Check those you take and indicate how often you have
a need for these products (i.e. Bayer Aspirin/daily:

Items                                        OTC Item        ____Frequency__

Allergies ____________________________________________

__Aspirin______________________________________________
__Caffeine_____________________________________________
__Cold/flu_____________________________________________
__Cough_______________________________________________
__Constipation__________________________________________
__Diarrhea_____________________________________________
__Drowsiness___________________________________________
__Eye or ear problems____________________________________
__Headache/Migraine____________________________________
__Heartburn/Stomach upset/gas____________________________
__Hemorrhoids_________________________________________

__Insomia_____________________________________________ 
__Muscle or joint pain____________________________________
__Rash/itching/dry skin/skin problems_______________________
__Restlessness/Nervous__________________________________
__Sinus______________________________________________
__Weight Gain_________________________________________

__Weight Loss _________________________________________
__Other (list) __________________________________________