Medication List Template
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1Rehabilitation Associates, Inc.
ROUTE METHODS
FREQUENCY TYPES
ID = INTRADERMAL (UNDER SKIN)
AC = BEFORE MEALS
MEDICATION LIST
IM = INTRAMUSCULAR
PC = AFTER MEAL
IV = INTRAVENOUS
PRN = WHEN NECESSARY
PO = BY MOUTH
EVERYDAY = (no abbreviation)
PR = BY RECTUM
EVERY OTHER DAY = (no abbreviation)
Patient Name: ________________________________
SUBQ = UNDERSKIN
EVERY HOUR = (no abbreviation)
SL = UNDER THE TONGUE
2X/DAY = (no abbreviation)
Patient DOB: _________________________
SUPP = SUPPOSITORY
3X/DAY = (no abbreviation)
Date of Eval: __________________________
RIGHT EYE = (no abbreviation)
LEFT EYE = (no abbreviation)
OFFICE USE
Medication
Prescribing MD
Dosage
Frequency
Route
Modifications while on program
○ Add _______ ○ Stopped taking _____
1.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
2.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
3.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
4.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
5.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
6.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
7.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
○ Add _______ ○ Stopped taking _____
8.
○ Modification as noted ______________
○ Therapist Initials/Date: ____________
Therapist
Therapist
Therapist
Therapist
Initials: ______ Signature: ____________________________
Initials: ______ Signature: ____________________________
3/21/16
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