Medication Log Template

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Medication Log
Please list all current medications for ____________________________________________
(patient’s name)
as of ________________________________
(date)
For Clinician Use Only
New
D/C
Date/Initials
Medication
Dosage
Are you allergic to latex? (please circle)
YES
NO
Do you have any known allergies? (drug or other)
YES
NO
if YES, please
list below:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Therapist signature:____________________________
Date:____________
Time:________
2012

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