MEDICATION LIST

Etheridge Family Medicine, LLC

Barbara A. Etheridge, MD

27 Clyde Rd, Suite 102

Somerset, NJ 08873

732-246-0057phone

732-745-7070 fax
MEDICATION LIST

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS FOR EACH AND EVERY OFFICE VISIT.
*Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient Gender*
Patient Birth Date*

MonthDayYear
Patient Drug/Medication Allergies & Allergic Reactions
Allergic to Mold/Pollen/Dust?*

YesNoUnknown
Any Drug/Medication Allergies?*

YesNoUnknown
List Drug/Medication Allergies & Reactions:

Name of Medication / Allergic Reaction0/300
Patient Medications

Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.

Please List All Medications ( example: Levothyroxine 25 mcg 1 tablet 2 per day

Patient Drug/Medication Allergies & Allergic Reactions