Medication History Form printable pdf download

Medication History Record

Name: ____________________________________________________________________________________________

Reference Record #: __________________ Tel: (home) _________________ (Mobile) ___________________________

□

Date of Birth: ____________________________

Gender:

Male

Female

Insurance Details: __________________________________________________________________________________

Current Diagnosis

Any Allergies

Family medical history of allergies and any notable conditions

Occupation: _________________ Location: ________________

Source of Medications:

Hobbies:

□ local pharmacy

□ mail order

□ Internet

____________________________________________________

□ samples

□ foreign (Canada / Mexico)

Travel: □ Domestic □ International

□ other (Provide details below)

% of travel involved ___________________________________

_____________________________________

Any Cost Issues*: □ No □ Yes

Immunizations (last 5 yrs) □ Td ________________________

_____________________________________

□ Flu _______________

□ Pneumonia __________________

Any Accessibility Issues*: □ No □ Yes

_____________________________________

Diet: □ Balanced □ Frequency _________________________

Medication storage location*

Caffeine: □ No □ Yes

amount _____

source ____________

_____________________________________

Tobacco: □ No □ Yes amount ____ # Years ____ Quit on _____

Are the containers labeled*: □ Yes □ No

Alcohol : □ No □ Daily □ Weekly □ Monthly amount ______

_____________________________________

Are they accessible to children*: □ Yes □ No

Any recreational drugs or steroids used?

_____________________________________

Are expired medications discarded*: □ Yes □ No

_____________________________________

* Include any notes additional info as required.

Current Prescription Medications Used

Name of the medication

Dosage

Frequency

Taken

Allergic reactions

Prescribed For

last on?

regularly?

or Side Effects

Prescription Medications not being used currently, but used anytime in the past 3 months

Name of the medication

Dosage

Frequency

Taken

Side Effects

Reason for Stopping

last on?

Medication History Form

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