New Patient Medical History Questionnaire Page 2
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2Patient Medication Log
Patient Name: ___________________________________________
Date of Birth:_____________________________
Primary Care Physician: ___________________________________
Physician’s Phone: _________________________
Pharmacy:______________________________________________
Pharmacy Phone: __________________________
Allergies to Medications
Penicillin (PCN)
Sulfa
Barbiturates
Insulin
Iodine or Contrast Dyes
Aspirin, Ibuprofen & Naproxen
Novocain,
Lidocaine, Epinephrine
General Anesthesia
Anti-Seizure Medications
Pain Medication (Codeine, Vicodin, Celebrex, Vioxx,
Lortab, etc.)
Other: _________________________________________________________________________________________
Current Prescription Medication Regiment
Medication
Dosage
Frequency
Begin Date
End Date
Special Notes
Current Non-Prescription Medication or Supplement Regiment
Medication
Dosage
Frequency
Begin Date
End Date
Special Notes
Form 2 Revised 01/04/2012
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Parent category: Medical