Patient’s Name: _______________________ Date: __________________________ Please list all your medications, including all prescriptions, over the counter medications, herbals, vitamins, minerals, and dietary supplements, and the dosage, frequency and administration method for each medication. Medication Dosage Frequency Method of Administration Needed As Oral daily Once Sublingual daily Twice Topical times daily injection Three Subcutaneous Other: Other: Needed As Oral daily Once Sublingual daily Twice Topical times daily injection Three Subcutaneous Other: Other: Needed As Oral daily Once Sublingual daily Twice Topical times daily injection Three Subcutaneous Other: Other: Needed As Oral Once Sublingual daily Twice Topical times daily injection Subcutaneous Other: Needed As Oral Once Sublingual daily Twice Topical times daily injection Three Subcutaneous Other: Other: Needed As Oral daily Once Sublingual daily Twice Topical times daily injection Three Subcutaneous Other: Other:
Patient’s Name: _______________________ Date: __________________________ Please list all your medications, including all prescriptions, over the counter medications, herbals, vitamins, minerals, and dietary supplements, and the dosage, frequency and administration method for each medication. Medication Dosage Frequency Method of Administration As Needed Once daily Twice daily Three times daily Other: Oral Sublingual Topical Subcutaneous injection Other: As Needed Once daily Twice daily Three times daily Other: Oral Sublingual Topical Subcutaneous injection Other: As Needed Once daily Twice daily Three times daily Other: Oral Sublingual Topical Subcutaneous injection Other: As Needed Once Twice daily times daily Oral Sublingual Topical Subcutaneous injection Other: As Needed Once Twice daily Three times daily Other: Oral Sublingual Topical Subcutaneous injection Other: As Needed Once daily Twice daily Three times daily Other: Oral Sublingual Topical Subcutaneous injection Other: