List all medications individual in care is taking including medications prescribed by this provider, medications prescribed by outside prescribers as well as herbal remedies, vitamins, nutraceuticals, or over-the-counter drugs. Supply: Dosage / Route / Rationale for Name of Date Medication Amount / Status Purpose Source of Knowledge Frequency Change Prescriber Refills Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report Prescriber New/Adj. Outside Prescriber Continue Pharmacy Discont. Individual Self-Report
List all medications individual in care is taking including medications prescribed by this provider, medications prescribed by outside prescribers as well as herbal remedies, vitamins, nutraceuticals, or over-the-counter drugs. Date Medication Dosage / Route / Frequency Supply: Amount / Refills Status Purpose Rationale for Change Name of Prescriber Source of Knowledge New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report
nyscri-at-summary-list.docx