Medication History Form (Page 2 of 2) in pdf

Medication History Form Page 2

INSTRUCTIONS

 Please NOTE that this is a medication history form that will be used to keep track of

current medications you are taking.

 This form can serve as a template medication history if admitted to a health care

facility.

Patient or Caregiver

1. Please list medications with attention to the entire description. (e.g., note if XR,

SR, XL. Are at the end of the medication name). This information can be found

on your prescription labels.

2. Please include any medications you are currently prescribed but not taking.

3. Please indicate reasons why not taking these medications.

4. At discharge from this service please keep this with you and share with other

Healthcare providers.

Nurse

1. Review the completed Medication History Form with patient and family as part of

the overall history.

2. This form will be used to supplement current history forms.

3. Sign in the “reviewed by” signature block.

4. Cross through medications that are discontinued.

5. Contact the practitioner and any related pharmacy services if any compliance

issues are noted.

Medication History Form Page 2