Medication Reconciliation Form
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1MEDICATION RECONCILIATION FORM:
: ___________________
Date: _____________________ Patient’s First Name:_______________________M.I.:_____ Last Name
_________________________________________________________________________________________
Acct#
Dear Patient, Please list all of your medication that you are currently taking. This includes all over the counter, vitamins, herbal,
recreational and alternative medication. Pharmacy Name: ________________________ phone #: ________________________
• Are you currently taking birth control? □ Yes □ No
• Pregnant □ Yes □ No Due Date: ______________________
• Breastfeeding: □ Yes □ No □N/A
• Allergies: _____________________________________________________________________________________________
Today’s
Time
FREQUENCY
STATUS AT VISIT
MEDICATION
DOSE
DATE
IV
(indicate times per day or
of last
mg
(For office use only)
week)
dose
Resume/Stop
Date
1
1x 2x 3x 4x / day / week
1x 2x 3x 4x / day / week
2
3
1x 2x 3x 4x / day / week
1x 2x 3x 4x / day / week
4
1x 2x 3x 4x / day / week
5
1x 2x 3x 4x / day / week
6
1x 2x 3x 4x / day / week
7
8
1x 2x 3x 4x / day / week
1x 2x 3x 4x / day / week
9
1x 2x 3x 4x / day / week
10
1x 2x 3x 4x / day / week
11
1x 2x 3x 4x / day / week
12
13
1x 2x 3x 4x / day / week
1x 2x 3x 4x / day / week
14
1x 2x 3x 4x / day / week
15
Date Updated: ___ / ___ / ___ Initials: _______ Date Updated: ___ / ___ / ___ Initials: _______ Date Updated: ___ / ___ / ___ Initials: _______
Date Updated: ___ / ___ / ___ Initials: _______ Date Updated: ___ / ___ / ___ Initials: _______ Date Updated: ___ / ___ / ___ Initials: _______
(will be completed by doctor’s office):
New Medications to be added at this visit
Date
Medication
Dose
Frequency:
As needed
Call if any
Stop if any
mg/cc’s
How many times daily
For pain
reaction
bleeding
1
1x 2x 3x 4x / day
2
1x 2x 3x 4x / day
3
1x 2x 3x 4x / day
4
1x 2x 3x 4x / day
5
1x 2x 3x 4x / day
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Orig 1/9/2006 , Revised 11/21/08
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