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Current Medications Form
Please include over the counter medications
Please correct the errors described below.
Patient Name
Date of Birth
1.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
2.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
3.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
4.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
5.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
6.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
7.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
8.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
9.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
10.
Name of medication
Dosage/ Frequency
Is the medication working?
Yes
No
Maybe
Length of medication use
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