Medications and Hospitalizations Please include all your current prescription medications (sleeping pills, birth controls pills), non-prescription medications (aspirin, antacids, laxatives, antihistamines), vitamins, minerals, herbs, etc. (Include dose for each.) Attach a separate sheet, if necessary. Medication Dose per day Reason for use Prescriber Date started Med. Hospitalization, surgeries or serious injuries (dates and types of illness or operation): Allergies Drugs, food or other substances Reaction Name Date Health Data (Please fill in completely) Exam Date Result Due Screening Recommendations Last Pap Smear/Gynecologic Exam Yearly starting after first intercourse or age 21 Mammogram Yearly starting at age 40 Bone Density Test (DEXA) Every 2 years starting at age 50 Colonoscopy Every 10 years starting at age 50
Medications and Hospitalizations Please include all your current prescription medications (sleeping pills, birth controls pills), non-prescription medications (aspirin, antacids, laxatives, antihistamines), vitamins, minerals, herbs, etc. (Include dose for each.) Attach a separate sheet, if necessary. Medication Dose per day Reason for use Prescriber Date started Med. Hospitalization, surgeries or serious injuries (dates and types of illness or operation): Allergies Drugs, food or other substances Reaction Name Date Health Data (Please fill in completely) Exam Date Result Due Screening Recommendations Last Pap Smear/Gynecologic Exam Yearly starting after first intercourse or age 21 Mammogram Yearly starting at age 40 Bone Density Test (DEXA) Every 2 years starting at age 50 Colonoscopy Every 10 years starting at age 50
WatersEdge-New-Patient-Health-Record%20with%20OfficeGuide%202016.docx