"Patient Medication List Template"

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UPPER CUMBERLAND UROLOGY ASSOCIATES, P.C.
PATIENT MEDICATION LIST
Patient name:__________________________________Date:____________Chart#_______
Please bring all medications or an updated list of medications with you each time you have an ap-
pointment.
Please list all of your prescriptive drugs, include any supplements or over-the-counter medications.
Medication
Dose
Times/Day
Purpose
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please check if you are on any of the following anticoagulant medications:
Aggrenox or dipyridamole
Arixtra or fondaparinux
Aspirin
Coumadin or warfarin
Fragmin or dalteprarin
Heparin
Lovenox or enoxaparin
Persantine or dipyridamole
Plavix or clopidrogrel
Ticlid or diclopidine
Please check if you are on any of the following nonsteroidal anti-inflammatory drugs
(NSAIDS):
Advil
Aleve
Anaprox
Ansaid
Arthrotec 50
Cataflam
Celebrex
Clinoril
Daypro
Feldene
Indocin
Lodine
Mobic
Motrin
Nalfon
Naprelan
Naprosyn
Oruvail
Relafen
Voltaren
Please sign here if you refuse to fill out this form._____________________________________
____________________________________________________________________________
UPPER CUMBERLAND UROLOGY ASSOCIATES, P.C.
PATIENT MEDICATION LIST
Patient name:__________________________________Date:____________Chart#_______
Please bring all medications or an updated list of medications with you each time you have an ap-
pointment.
Please list all of your prescriptive drugs, include any supplements or over-the-counter medications.
Medication
Dose
Times/Day
Purpose
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please check if you are on any of the following anticoagulant medications:
Aggrenox or dipyridamole
Arixtra or fondaparinux
Aspirin
Coumadin or warfarin
Fragmin or dalteprarin
Heparin
Lovenox or enoxaparin
Persantine or dipyridamole
Plavix or clopidrogrel
Ticlid or diclopidine
Please check if you are on any of the following nonsteroidal anti-inflammatory drugs
(NSAIDS):
Advil
Aleve
Anaprox
Ansaid
Arthrotec 50
Cataflam
Celebrex
Clinoril
Daypro
Feldene
Indocin
Lodine
Mobic
Motrin
Nalfon
Naprelan
Naprosyn
Oruvail
Relafen
Voltaren
Please sign here if you refuse to fill out this form._____________________________________
____________________________________________________________________________