Medication List

ARTHRITIS  CENTER  OF  CONNECTICUT

BRIAN  PECK,  M.D.      RICHARD  S.  POPE,  PA-­C      MATTHEW  LETKO,  PA-­C      JON  LUM,  PA-­C      TRISHNA  WALSH  PA-­C

MEDICATION  LIST

 

For  Patients  of  Dr.  Brian  Peck  –  203-­755-­5555

Keep  updated  copy  in  wallet  at  all  times.

Include  vitamins,  calcium  etc.

Your  Name_____________________________    Date___________________

 

                   Name  Of  Med.                                                                                          Milligrams                                                              

   

 

                   

             How  Often

 

 

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Please  rate  your  pain  for  today  on  the  scale  below

1    2    3    4    5    6    7    8    9    10

(1)  No  pain        (5)    Moderate  pain      (10)    Severe  pain