Medication History Form Page 2
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1
2Any OTC medications used:
Symptom
Medication & Dosage
Frequency
Started taking on
Last taken on
Side effects
Pain
/
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Diarrhea or constipation
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Nausea
/
/
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Heartburn
/
/
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Cough
/
/
/
/
Congestion/ Sinus
/
/
/
/
Allergies
/
/
/
/
Sleeping Aid
/
/
/
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Skin problems
/
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Weight loss
/
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Anxiety
/
/
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Depression
/
/
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Menstrual issues
/
/
/
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Menopause
/
/
/
/
Vitamins/Herbs
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Notes/Comments: _______________________________________________________________ _________________________________
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