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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) __________________________________________ | 
