Medications & Allergies
Date Completed
*
/
Month
/
Day
Year
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Emergency Contact
*
Relationship
*
Allergies & Drugs to Avoid
Current Medications (including prescription, over-the-counter medicines, dietary supplements, vitamins & herbs)
Rows
Medication Name
Dosage
How Often
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14
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