Patient Medication List Template

NAME:

Brattleboro Memorial Hospital

PATIENT MEDICATION LIST

ALLERGIES:

This is NOT an order form

Source of Medication List – Check all used: ___Patient/Family recall, ____ Patient Medication List, ___ List from other facility

___Physician, ____ Last “Discharge Instructions”; _____ Other:

FLU VACCINE DATE RECEIVED :

PNEUMONIA VACCINE DATE RECEIVED:

How

Person Who

Last dose

Dose

Route

Medication name

often

Listed Drug

Date and

Time

(Write Clearly)

taken

and Date

LIST BELOW: Vitamins, Herbals, Supplements, Over the counter drugs

All above medications reviewed on Admission to____________/________________________________DATE:________

(signature of MD, DO, NP, CNM, PA)

All above medications reviewed on TRANSFER to____________/________________________________DATE:________

(signature of MD, DO, NP, CNM, PA)

Page ____ of _____

__copy to Pharmacy

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Parent category: Medical