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):
