Patient Medication List

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PATIENT MEDICATION LIST
Patient Name ___________________________________
Date This Form Completed _________________
LIST ALL CURRENT PRESCRIPTION MEDICATION
CURRENT MEDICATION
DOSE (mg) & MONTHS
REASON PRESCRIBED
RESPONSE TO MEDICATION
PRESCRIBING
DATE BEGAN
NAME
TAKEN
FOR
PHYSICIAN’S
TAKING THIS
NAME
MEDICATION
1.
2.
3.
4.
5.
LIST ALL CURRENT OVER THE COUNTER MEDICATION, VITAMINS, SUPPLEMENTS, NEUTRICEUTICALS, HERBALS & ALL OTHERS
CURRENT MEDICATION
DOSE (mg) & MONTHS
REASON
RESPONSE TO MEDICATION
DATE BEGAN
NAME
TAKEN
TAKING
TAKING THIS
MEDICATION
1.
2.
3.
4.
PAST PSYCHIATRIC MEDICATION ONLY
PAST PSYCHIATRIC
DOSE (mg) & TIME(S)
REASON PRESCRIBED
RESPONSE TO MEDICATION
PRESCRIBING
DATE BEGAN
MEDICATION NAME
TAKEN
FOR
PHYSICIAN’S
TAKING THIS
NAME
MEDICATION
1.
2.
3.
4.
Please use back of form for additional space if needed

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