Routine And Prn Medications Log Template

ROUTINE AND PRN MEDICATIONS

Patient Name: ____________________________________________________________ Date of Birth: _____/_____/_____

Drug Sensitivity/Allergies:________________________________________________________________________

Please list all medications you are currently taking with the dosage amount and frequency. This list should include both

prescription drugs, over the counter drugs, and vitamins.

MEDICATION NAME

DOSAGE

FREQUENCY

* Any medication changes should be entered on a new line and initialed. When medication is discontinued, please highlight and date the entry.

REVIEWED BY

Initials

(INITIAL & DATE):

COMPLETED BY

Date

OFFICE STAFF ONLY

REVISED 1/6/15

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Parent category: Medical