"Medication Flow Sheet"

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Allergies: ______________________________
MEDICATION FLOW SHEET
_________________________________________
_________________________________________
Last name: _____________________
First Name: _________________ MI: ________
_________________________________________
Pt #: ___________________
DOB: ______________
Male □
Female □
_________________________________________
Pharmacy Name: _______________________________
Pharmacy Phone #: ______________________________
Refills*
Start/Stop
Pt. Med
(date, amount, initials)
Date
Medication
Dose/Route/Frequency
Prescriber
st
nd
rd
th
Dates
Education/Source*
1
2
3
4
* Patient education ‘Source’ may be written, verbal, video, or web-based; Refills should follow strict office policy, requiring patient be seen at
regular intervals (frequency to depend on drug indications and medical condition)
Allergies: ______________________________
MEDICATION FLOW SHEET
_________________________________________
_________________________________________
Last name: _____________________
First Name: _________________ MI: ________
_________________________________________
Pt #: ___________________
DOB: ______________
Male □
Female □
_________________________________________
Pharmacy Name: _______________________________
Pharmacy Phone #: ______________________________
Refills*
Start/Stop
Pt. Med
(date, amount, initials)
Date
Medication
Dose/Route/Frequency
Prescriber
st
nd
rd
th
Dates
Education/Source*
1
2
3
4
* Patient education ‘Source’ may be written, verbal, video, or web-based; Refills should follow strict office policy, requiring patient be seen at
regular intervals (frequency to depend on drug indications and medical condition)