Patient Medication Questionnaire

  • PATIENT INFORMATION

  • CURRENT MEDICATIONS

    Please provide a list of all of your current medications. These include prescriptions, over-the-counter meds, herbs, and nutritional supplements (vitamins, minerals, dietary). Please include the route of transmission as well (oral, topical, injection).

  • Prescriptions Medications

  • Name of MedicationDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Physician 
    Click on the plus sign to add more.

  • Over-The-Counter Meds

  • over-the-counterDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
    Click on the plus sign to add more.

  • Herbs

  • HerbsDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
    Click on the plus sign to add more.

  • Nutritional Supplements

  • Nutritional SupplementDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
    Click on the plus sign to add more.