"Home Medications and Allergy List - Eye&ear Clinic Wenatchee"

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Home Medications and Allergy List
Patient: _________________________________ Date of Birth: ________________________
Please list all medications you are currently taking at home. Include all prescription and over-
the-counter medications, vitamins and nutritional supplements.
Medication Name
Dose
Frequency
Ibuprofen
200 mg
Every four hours
Example
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Please list all medical allergies below:
Allergy
Reaction
Example
Penicillin
Itchy rash
(Forms/Clinic Wide/Home Medications and Allergy List)
11-11-13/lka
Home Medications and Allergy List
Patient: _________________________________ Date of Birth: ________________________
Please list all medications you are currently taking at home. Include all prescription and over-
the-counter medications, vitamins and nutritional supplements.
Medication Name
Dose
Frequency
Ibuprofen
200 mg
Every four hours
Example
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Please list all medical allergies below:
Allergy
Reaction
Example
Penicillin
Itchy rash
(Forms/Clinic Wide/Home Medications and Allergy List)
11-11-13/lka