Current List of Medications for Provider

Include prescriptions, over-the-counter medicines, vitamins, supplements, inhalers, creams, and injections.

Page 1 of 2

Patient nameDate updatedDoctor or clinicAppointment date

Allergies or past medication reactions

Current medicines 1–15

#	Medicine and strength	How much and when	Reason	Prescriber
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Current List of Medications for Provider

Include prescriptions, over-the-counter medicines, vitamins, supplements, inhalers, creams, and injections.

Page 2 of 2

Patient nameDate updatedDoctor or clinicAppointment date

Current medicines 16–30

#	Medicine and strength	How much and when	Reason	Prescriber
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Questions or recent changes