MEDICATION  LIST

NAME________________________________

ALLERGIES___________________________

______________________________________

______________________________________

______________________________________

MEDICATION

NAME & MG                      TIMES TAKEN/ DAY

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

MEDICATION SIDE EFFECTS & REACTIONS

MEDICATION NAME               SIDE EFFECTS

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

MEDICAL RECORD RELEASE FORM

The medical record release form may be obtained by:

• email to info@mypatienthandbook.com

• postal mail sent to:

     Bend of the River Books

     POB 330645

     Miami, FL 33233  

The medical record release form will be available on this website soon.

WWW.MYPATIENTHANDBOOK.BLOGSPOT.COM

has more useful information and links.