Medication And Allergy Worksheet printable pdf download

Medication And Allergy Worksheet

Medication and Allergy Worksheet

Instructions: In addition to the questionnaire you will complete online or on the computer in our office, we

need to get a complete list of your allergies and medications. We review and update your medication list each

time you come to see a provider at Moffitt. Please complete this worksheet at home and bring it with you to

your appointment.

Allergies: Please list all things that you are allergic to including medications, foods, x-ray dyes, and iodine.

For each item, include a description of the reaction you have to it.

I have no known allergies.

Source of allergy

Reaction

Medications: Please list ALL prescription and over-the-counter medications (drugs) including eye drops,

topical patches, and injections (including vitamins and herbal products) you are taking or receive.

I am not taking any medications.

How often is the

medication used or

Route (pill,

# of

injection,

taken? (times per

Date

Reason for

Duration or

Name of medication

Strength

tablets

etc.)

day/week/month)

started

using

Stop date?

Patient Name: _____________________________

Worksheet Only – Not for Scanning

Date Of Birth: _____________________________

Medication And Allergy Worksheet