"Patient Medication List Template - Eye-Q"

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Patient Medication List
Please list every prescription and over-the-counter drug you are presently taking. Be sure to include
the strength and dose of each medication, and how often it is taken. Bring this form with you to your
surgery appointment. You can also keep this form in your wallet or purse for future reference.
Medication
Strength
Dose
Frequency
1
2
3
4
5
6
7
8
9
10
11
12
13
Please list all Allergies
1
4
7
2
5
8
3
6
9
RN Signature if completed by staff__________________________________ Date_____________
Patient Medication List
Please list every prescription and over-the-counter drug you are presently taking. Be sure to include
the strength and dose of each medication, and how often it is taken. Bring this form with you to your
surgery appointment. You can also keep this form in your wallet or purse for future reference.
Medication
Strength
Dose
Frequency
1
2
3
4
5
6
7
8
9
10
11
12
13
Please list all Allergies
1
4
7
2
5
8
3
6
9
RN Signature if completed by staff__________________________________ Date_____________