MEDICATION LIST

MEDICATION LIST

We update our medication lists every year. Please let your therapist know your current medications (we do not need dosages).
*Type your Name here*

First NameLast Name
Patient Birth Date*

MonthDayYear
Take prescription medication (s)Do not take prescription medication (s)

Please List All Medications

Rows	Medication Name
1
2
3
4
5
6
7
8
9
10
11
12

Tobacco/Alcohol Usage
Yes, I use tobacco products dailyYes, sometimes I use tobacco productsNo, I quit smoking/using tobaccoNo, I have never smoked or used tobacco
1-4 drinks/month1-2 drinks/day3-4 drinks/day5+ drinks/day0 drinks
Today's Date*

MonthDayYear
Type Security Code Below*
Should be Empty: