My Medication List

Affiliates in OB/GYN, P.A.

MY MEDICATION LIST :

Patient Name:_______________________________Date of Birth:________________

Do you have any allergies to any medications? YES NO

Medication

Reaction

List ALL medications you are currently taking including overthecounter medication, vitamins,

dietary and herbal supplements.

Name of

Dose/Strength

How many time a

Prescribed By

Why do you take

medication

day do you take

this medication?

this?

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Parent category: Medical