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 Name Last Name
Patient Birth Date *

Month Day Year
I (or my child) *

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

Please List All Medications

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

Tobacco/Alcohol Usage
Tobacco Usage: *

Yes, I use tobacco products daily Yes, sometimes I use tobacco products No, I quit smoking/using tobacco No, I have never smoked or used tobacco
Alcohol Consumption *

1-4 drinks/month 1-2 drinks/day 3-4 drinks/day 5+ drinks/day 0 drinks
Today's Date *

Month Day Year
Type Security Code Below *
Should be Empty: