Medication Form

Medications that you are currently taking
Please list ALL medications taken on a daily basis. This includes all vitamins, herbals, and over-the-counter medications.
Medication Name
Dose / Strength
Times taken per Day
Prescribing Doctor
Reason for Taking Medication
Please list any Medications you have tried in the past for this current problem:
Who Prescribed
Please list ALL Medication Allergies:
Pharmacy Address (if known):