Medication List

Keep your medication list up to date, so in case of a relapse, you can accurately report this information to your healthcare provider(s). Some medications could be causing new or worsened symptoms as a side effect, or they may possibly interfere with other treatments.

Pharmacy Name:_____________________________________________________
Address:___________________________________________________________
Phone Number:______________________________________________________
Insurance:_________________________________________________________
Policy Number:_____________________________________________________
Group Number:______________________________________________________
Insurance Contact Info:____________________________________________

Medication #1
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________

Medication #2
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________

Medication #3
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________

Medication #4
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________

Medication #5
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________

Medication #6
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________


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