For general education only. This information does not diagnose a condition or replace medical advice. Your provider will determine which evaluation or treatment is appropriate for you.
Include the full list
Include prescription medicines, over the counter products, vitamins, and supplements. Copy details from the label rather than guessing.
This is a record to discuss, not a recommendation to start, stop, or change anything. Bring labels or packaging if you are unsure.
Name: ____________________________ Date: __________________
Medicines and supplements
Name and formulation
Prescribed instructions or label details
Reason I take it and who prescribed it
When I started and any concerns
Additional items
Other medicines or supplements
Allergies and previous reactions
Questions about interactions or side effects