MEDICATION LIST

MEDICATION LIST
PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS FOR EACH AND EVERY OFFICE VISIT.
*I understand that Medical Provider Lyris Verdura-Dominic and/or Staff Medical Provider and/or Staff relies on the medication information I provide to her/him for my care, and that any medication mis-information or omitted information can result in hospitalization or death. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete and I will request new form I will complete and provide the provider with written changes via new updated form completion.
*Type your Name here *

First Name Middle Name Last Name Suffix (Jr, Sr, III, ect)
Patient Gender *
Patient Birth Date *

Month Day Year
Patient Phone Number *

Area Code Phone Number
Patient Drug/Medication Allergies & Allergic Reactions
Allergic to Mold/Pollen/Dust? *

Yes No Unknown
Any Drug/Medication Allergies? *

Yes No Unknown
List Drug/Medication Allergies & Reactions: *

Name of Medication / Allergic Reaction 0/300
Patient Medications

Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.
Do you take any medications including vitamin supplements *

No, I do not Yes, I do

Please List All Medications

Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage: *

Yes, I Smoke Daily Yes, Sometimes I Smoke No, I Quit Smoking No, I Never Smoked
Date I Quit Smoking: *

Month Day Year
# Cigarettes per day? *
Alcohol Consumption *

I don't drink 1-4 drinks/month 1-2 drinks/day 3-4 drinks/day 5+ drinks/day
Caffeine Consumption *

I don't use caffeine 1-4 cups/month 1-2 cups/day 3-4 cups/day 5+ cups/day
Today's Date *

Month Day Year
Type Security Code Below *
Signature *

Clear
Should be Empty:

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Patient Drug/Medication Allergies & Allergic Reactions