Prescription Medications:

If you have a list, give it to the front office to photocopy.

Otherwise, please list all of the medications that you take on a regular or intermittent basis.

Name               Dose (mg)        # taken for each dose (1/2, one )          # times taken daily

1.   

2.

3.

4.

5.

6.

7.

Do you use any blood thinners:   Coumadin/Plavix/Aspirin/Aggrenox/Ticlid

Over the Counter

Circle any of the following that you take on a regular basis:

            Herbs/Laxatives/Sleeping Aides/Pain pills/ Acetaminophen(Tylenol)

Aspirin

Arthritis Pain Pills/NSAIDS/advil/ibuprofen/Aleve/naproxen etc.

Multivitamin

            Vitamin A/B6/Bcomplex/B12/C/ D/E/

Calcium/Magnesium/ iron

Herbal supplements

Milk thistle

Peptobismol

Lactaid/ Beano

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