Baseline Concomitant Medication Log
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1Baseline Concomitant Medication Log
[Can be used at baseline when collecting medical history and then at each visit or encounter to id any new or changed meds]
Subject ID _____________ Subject Initials _____________
Study #__________________ Date:____________________
List any medications you currently take including over the counter, vitamins, herbal products, etc.
Medication
Prescribed
Dosage
Strength
Route
Frequency
Date of First
Date of Last
Reason (check if due
(RX) or
(tsp.,
(mg.
(PO, IV,
Dose
Dose
to a new adverse
Over the
tablet)
mcg,
IM, etc.)
mm-dd-year
mm-dd-year
event)
Counter
units,
(OTC)
mL)
200 mg
PO
PRN
6-1997
ongoing
Backpain
Sample
RX
1 tablet
AE
Ibuprofin
Twice/day
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
RX
OTC
6/27/07 Sample_Concomitant_Medication_Log.doc
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Parent category: Medical