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Letter to Doctor-Medications
FORM LETTER TO YOUR DOCTOR ON YOUR MEDICATIONS
(FILL IN YOUR NAME) CURRENT MEDICATION/OTC TREATMENTS
Date:______________________________
Provided to Doctor___________________
Patient:____________________________(fill in)
Condition:__________________________ (fill in ie HD)
Address:___________________________
________________________________
____________________________
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 for you to manage all of the medications/Over-The-Counter (OTC) products I am taking 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
1.____________ _____________ _________ _____________ ___________
2.____________ _____________ _________ _____________ ___________
3.____________ _____________ _________ _____________ ___________
4.____________ _____________ _________ _____________ ___________
5.____________ _____________ _________ _____________ ___________
6.____________ _____________ _________ _____________ ___________
7.____________ _____________ _________ _____________ ___________
8.____________ _____________ _________ _____________ ___________
9.____________ _____________ _________ _____________ ___________
10.____________ _____________ _________ _____________ __________
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 neurologist, primary care physician etc) 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 | 
