(Fill In Your Name) CURRENT MEDICATIONS/OTC 

Date: ____________________________________
Provided to Doctor__________________________

Patient:___________________________________
Condition/Disease:__________________________
Address:__________________________________
City/ST____________________Zip_____________
Tel Number: Area Code ( ) ___________________

If applicable, spouse/caregiver contact and telephone number:
_________________________________________

Dear Dr. (fill in)

The following is a list of medication(s) and alternative products that I am presently taking. 
As my (fill in: primary care/neurologist etc), this information is being provided to you in 
order that you manage all of the medications/Over-The-Counter (OTC) products to avoid 
any potential serious side-affects or ineffectiveness of a particular drug as a result of its 
combination with another drug or OTC product.

Brand Name	Generic Name	Dosage	Times	Frequency	Comments	

						

						

						

						

For my medical records, I currently have the following (describe):

Drug allergies _____________________________________________
Medication allergy__________________________________________
Reaction Experienced: ______________________________________

In addition to the above, I am also taking the following vitamins, herbs or other supplements:
1.____________ _____________ _________ _____________ ___________
2.____________ _____________ _________ _____________ ___________
3.____________ _____________ _________ _____________ ___________
4.____________ _____________ _________ _____________ ___________
5.____________ _____________ _________ _____________ ___________

As my (fill in) _________________________I appreciate your concern for my health and am confident that you will review this list when it is updated to advise me of any potential concern 
you may have.

Respectfully yours
(sign)

Copy: Patient's Medical Record File