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 
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  • Over-The-Counter Meds

  • over-the-counterDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
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  • Herbs

  • HerbsDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
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  • Nutritional Supplements

  • Nutritional SupplementDosageFrequencyRoute of transmission (e.g. oral, topical, injection)Purpose 
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