Form Pd903991 - Medco Pharmacy Mail-Order Form Page 4
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4SECTION 3: Your medical conditions
Has your doctor ever told you that you have any of the conditions listed below? If so, fill the oval completely next to all that apply.
Allergies, hay fever (allergic rhinitis)
Heart failure (CHF)
Arthritis
Hemophilia and hemophilia-like conditions
Asthma
High blood pressure (hypertension)
Bladder control problem (urinary incontinence)
High blood sugar (diabetes)
Brittle bones (osteoporosis)
High cholesterol (hypercholesterolemia)
Chest pain (angina)
Inflammatory bowel disease
Migraine headache
Crohn’s disease
Overactive thyroid (hyperthyroid)
Depression
Peptic, stomach, or duodenal ulcer
Emphysema (COPD, chronic bronchitis)
Poor circulation in the legs (peripheral
Enlarged prostate (benign prostatic hyperplasia,
vascular disease)
BPH)
Seizures (epilepsy)
Gastric reflux, heartburn, or esophagitis (GERD)
Glaucoma
Stroke (TIA)
Heart attack (myocardial infarction)
Underactive thyroid (hypothyroid)
If you have a medical condition that is not listed above, print the name of that medical condition in the
space below. Example: breast cancer
other:
other:
SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
Prilosec OTC
®
/omeprazole
Advil
®
/ibuprofen
Aleve
®
/naproxen
Sominex
®
, Nytol
®
/diphenhydramine
Bayer
®
/aspirin
Tagamet
®
/cimetidine
Benadryl
®
/diphenhydramine
Tylenol
®
/acetaminophen
Orudis KT
®
/ketoprofen
Zantac
®
/ranitidine
Pepcid AC
®
/famotidine
If you take a nonprescription medication that is not listed above, print the name of that medication in
the space below.
other:
other:
SECTION 5: Patient prescription medications*
Please list the prescription medications you are currently taking in the space below. *Information
can be found on the prescription labels. If none, please check here. [ ] NONE
Did you complete both sides?
Thank you very much.
PD903991
7/10
A030
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Parent category: Business