Medication List

The current medication picture. Bring a fresh copy to every appointment.

Do not change medication without guidance from the appropriate licensed clinician.

Allergies & reactions

Known allergies

Adverse reactions / medications to avoid

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions