Medications Form

Please realize there is an important medical difference between true allergies to medications (e.g., rashes, shock) versus unacceptable side effects to medications. Please separate these as best as you can. When filling out the current medications section, please include vitamins and any other over-the-counter meds or supplements taken on a regular basis. If you have a separate list, it should include dosage size and times of administration as does this form.

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Patient Information


Medication Information

No Drug Allergies / Reactions
This field is for validation purposes and should be left unchanged.