Medication History Form

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Patient Name:__________________________Date of Birth___________________Today’s Date__________
Medication History Form –
please read instructions on back of form prior to filling out
Thank you for choosing Ridgeline Endoscopy Center. A history and physical form and this medication history form are required paperwork and
will need to be updated each visit.
Your completed medication history form provides us with the necessary information we need to assure that we are providing a safe and
thorough evaluation of your needs.
PLEASE FILL IT OUT AND BRING THE COMPLETED FORM WITH YOU TO YOUR APPOINTMENT.
******************An incomplete or blank form could delay your appointment start time*******************
 Source of Medication List:___________________________________________
Primary Care Physician:
 NO HOME MEDICATIONS
 Unable to obtain medication history [give reason and
Patient’s Home Pharmacy:
follow-up plan (i.e. Family bringing in)]
Allergies/Reactions.…
 None
 LATEX
reaction:_________________
reaction ______________________
____________________________________________
 DEMEROL
reaction:_________________
reaction ______________________
____________________________________________
 EGGS
reaction:_________________
reaction ______________________
____________________________________________
Has a blood relative had a bad reaction to Anesthesia? Reaction __________________________  Have you had a bad reaction to Anesthesia? Reaction _______________________
Medications on Admissions
: Include prescriptions, over-the-counter medications, patches, inhalers, vitamins, herbal/home remedies, teas, dietary supplements
INSTRUCTIONS
Route
Schedule
Reason for taking
Medication [Include dosage form if
Dose
(oral,
(how often
When Last Taken
Medication
Medication
(e.g. diabetes,
indicated (EC, XL, ER, SR, CD, XR)]
(amount)
topical,
you take the
Date
Time
Started
Discontinued
Hypertension, etc.)
inject, etc)
med)
BELOW FOR STAFF USE ONLY
Date
Date
Date
Date
Signature
Signature
Signature
Time
Time
Time
Time

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