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Get Medicine Forms 2010-2024

Patient Medication History Form This form can also be found at www. uwmedicationlist. org The medicines you take are part of your health information. Please fill out this form or have your caregiver complete it and discuss it with your medical provider. If you need more space to list your medicines ask for another form. Please do not write on the back of this form. Patient Name Page Allergies Name of Substance drug or food Type of Reaction Check if none Do you react to latex or rubber gloves balloons etc with a rash wheezing etc. For female patients ONLY Are you currently pregnant Are you considering becoming pregnant Yes No Current Medications Prescription Drugs Strength Directions such as 2 tablets in the a.m. Prescribed By such as eye drops creams such as 50 mg Check box if taken only as needed. such as John Doe MD Over-the-Counter Medications such as aspirin Herbs Vitamins Minerals Etc. such as St. John s Wort STAFF ONLY Pharmacy Name PT. NO NAME DOB Phone Medication list reviewed prior to any change/deletion/addition by licensed provider Yes Pre-Surgery Yellow Packet or Return clinic visit within one week UW Medicine Health System Harborview Medical Center UW Medical Center Northwest Hospital Medical Center University of Washington Physicians Seattle Washington PATIENT MEDICATION HISTORY DO NOT THIN on FLOOR SCAN or FILE IN MED RECORD UH2301 REV DEC 10 WHITE OUTPT PATIENT COPY CANARY - PHARMACY WHITE H P OR PRE-SURG PKT. If you need more space to list your medicines ask for another form* Please do not write on the back of this form* Patient Name Page Allergies Name of Substance drug or food Type of Reaction Check if none Do you react to latex or rubber gloves balloons etc with a rash wheezing etc* For female patients ONLY Are you currently pregnant Are you considering becoming pregnant Yes No Current Medications Prescription Drugs Strength Directions such as 2 tablets in the a*m* Prescribed By such as eye drops creams such as 50 mg Check box if taken only as needed* such as John Doe MD Over-the-Counter Medications such as aspirin Herbs Vitamins Minerals Etc* such as St* John s Wort STAFF ONLY Pharmacy Name PT. NO NAME DOB Phone Medication list reviewed prior to any change/deletion/addition by licensed provider Yes Pre-Surgery Yellow Packet or Return clinic visit within one week UW Medicine Health System Harborview Medical Center UW Medical Center Northwest Hospital Medical Center University of Washington Physicians Seattle Washington PATIENT MEDICATION HISTORY DO NOT THIN on FLOOR SCAN or FILE IN MED RECORD UH2301 REV DEC 10 WHITE OUTPT PATIENT COPY CANARY - PHARMACY WHITE H P OR PRE-SURG PKT.

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