ADDITIONAL MEDICATIONS AND/OR DRUG ALLERGIES - - CONTINUED
Patient Name:
DOB:
Reaction
REGULAR MEDICATIONS
DOSE
SCHEDULE
DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
HISTORY / PHYSICAL - ADDITIONAL COMMENTS
PATIENT LABEL
Every Day (QD)
Twice a Day (BID)
Three Times a Day (TID)
At Bedtime (QHS)
Every AM (QAM)
As Needed (PRN)
Tylenol
Combigan
Zaditor
latanoprost
fish oil
Flovent HFA
dorzolamide-timolol
durezol
prolensa
ciprofloxacin
Ventolin HFA
cyclobenzaprine
losartan-HCTZ
pravastatin
Tylenol Arthritis
Cialis
CoQ10
Caltrate
timolol maleate
ProAir HFA
Diphenhist
glipizide
benazepril
Jardiance
humulin
Victoza
Aspirin
B complex
zoloft
Vitamin A
Vitamin B12
Vitamin C
Vitamin D
Vitamin D3
acetaminophen
atorvastatin
hydrocodone and acetaminophen
amoxicillin
levothyroxine
escitalopram
montelukast
esomeprazole
simvastatin
clopidogrel
metoprolol succinate
azithromycin
cetirizine
ezetimibe and simvastatin
lisinopril
oxycodone and acetaminophen
warfarin
hydrochlorothiazide
furosemide
cephalexin
fluticasone/salmeterol
pantoprazole
amlodipine
lansoprazole
metoprolol tartrate
venlafaxine
alendronate
valsartan
sertraline
ezetimibe
rosuvastatin
metformin
quetiapine
levofloxacin
valsartan and hydrochlorothiazide
atenolol
pioglitazone
duloxetine
prednisone
tamsulosin
albuterol
celecoxib
insulin glargine
risendronate
alprazolam
mometasone
sildenafil
fenofibrate
ramopril
propoxyphene napsylate and acetaminophen
ethinyl estradiol and drospirenone
trazodone
risperidone
acetaminophen and codeine
estrogens, conjugated/equine
losartan
donepezil
clonazepam
paroxetine
carvedilol
zolpidem
amoxicillin and clavulanate
dextroamphetamine and amphetamine
amlodipine and benazepril
digoxin
fluticasone propionate
gabapentin
sulfamethoxazole and trimethoprim
valacyclovir
triamterene and hydrochlorothiazide
pregabalin
ibuprofen
rosiglitazone
topiramate
lamotrigine
methylphenidate
lorazepam
latanoprost
ethinyl estradiol and norgestimate
fluoxetine
potassium chloride
rabeprazole
varenicline
clonidine
diazepam
lovastatin
glyburide
hydrochlorothiazide and losartan
tiotropium bromide
bupropion
cyclobenzoprine
olmesartan medoxomil
eszopiclone
fexofenadine
omeprazole
tolterodine
fluconazole
naproxen
olmesartan medoximil and hydrochlorothiazide
irbesartan
mematine
Zyrtec
NKDA
Codeine
Iodine
epinepherine
atorvastatin
hydrocodone and acetaminophen
acetaminophen
hydrocodone
amoxicillin
levothyroxine
escitalopram
montelukast
esomeprazole
simvastatin
clopidogrel
metoprolol succinate
azithromycin
cetirizine
ezetimibe and simvastatin
lisinopril
oxycodone and acetaminophen
warfarin
hydrochlorothiazide
furosemide
cephalexin
fluticasone/salmeterol
pantoprazole
amlodipine
lansoprazole
metoprolol tartrate
venlafaxine
alendronate
valsartan
sertraline
ezetimibe
rosuvastatin
metformin
quetiapine
levofloxacin
valsartan and hydrochlorothiazide
atenolol
pioglitazone
duloxetine
prednisone
tamsulosin
albuterol
celecoxib
insulin glargine
risendronate
alprazolam
mometasone
sildenafil
fenofibrate
ramopril
propoxyphene napsylate and acetaminophen
ethinyl estradiol and drospirenone
trazodone
risperidone
acetaminophen and codeine
estrogens, conjugated/equine
losartan
donepezil
clonazepam
paroxetine
carvedilol
zolpidem
amoxicillin and clavulanate
dextroamphetamine and amphetamine
amlodipine and benazepril
digoxin
fluticasone propionate
gabapentin
sulfamethoxazole and trimethoprim
valacyclovir
triamterene and hydrochlorothiazide
pregabalin
ibuprofen
rosiglitazone
topiramate
lamotrigine
methylphenidate
lorazepam
latanoprost
ethinyl estradiol and norgestimate
fluoxetine
potassium chloride
rabeprazole
varenicline
clonidine
diazepam
lovastatin
glyburide
hydrochlorothiazide and losartan
tiotropium bromide
bupropion
cyclobenzoprine
olmesartan medoxomil
eszopiclone
fexofenadine
omeprazole
tolterodine
fluconazole
naproxen
olmesartan medoximil and hydrochlorothiazide
irbesartan
mematine
Zyrtec
penicillin
amoxicillin
cephalexin
keflex
erythromycin
E-Mycin
clarithromycin
Biaxin
azithromycin
Zithromax
ciprofolxacin
Cipro
levofloxacin
Levaquin
ofloxacin
Floxin
co-trimoxazole
Bactrim
trimethoprim
Proloprim
tetracycline
Sumycin
Panmycin
doxycycline
Vibramycin
gentamicin
Garamycin
tobramycin
Tobrex
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