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MEDICATION SHEET
Today’s Date:
Pharmacy:
Drug Food Allergies/Reactions:
Please list your medications/herbs/vitamins below or indicate you have a list for the staff to photocopy,
and give to the receptionist. Provided for the staff to photocopy.
Medication/Herbal/
Vitamin Name
“Please Print”
Dosage/
Strength
Route –
How do you
take?
Example: By Mouth
Frequency –
How often do
you take?
Example: Twice a da
y
Last time
you took
medication?
Person completing the list: ________________________________________ Date: ________________
#0020585 Gate 6/10
Chart Copy
MEDICATION SHEET
Patient Name:_________________________ DOB: ____________
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