 |
|
| Doe, John | |
|---|---|
| Gender: | [insert gender] |
| DOB: | [insert dob] |
| Address: | [insert address] |
| Phone Number: | [insert phone number] |
| Pharmacy: | [insert pharmacy name/address] |
| Doctor: | [insert doctor info] |
| Insurance Plan: | [insert insurance plan] |
| Medication Name | Take | Form | Route | Size | Date Prescribed | Refills | Dispense Amount | Frequency | Indication |
|---|
| Dosage Compliance | ||||
|---|---|---|---|---|
| Drug Name | Morning | Afternoon | Evening | Special Instructions |
| Losartan Potassium | Taken | N/A | Taken | Take twice daily |
| Aspirin EC | N/A | Taken | N/A | Do not take with alcohol |
| Metaprolol Tartrate | Taken | N/A | Taken | Take before meal | Lantus Solostar | N/A | N/A | Taken | Take at bedtime |
| Eliquis | N/A | Taken | N/A | Take as needed |
| Pravastatin | Taken | N/A | N/A | Take once daily |
| Cyclobenzaprine | Taken | N/A | N/A | Take as needed |
| Amoxicillin | N/A | Taken | Not taken | Take every 12 hours for 7 days |
| Augmentin | Taken | N/A | Taken | Take every 12 hours for 7 days |
| Naprosyn | Taken | Taken | N/A | Take twice daily |
| Keflex | Taken | Taken | Taken | Take every 6 hours for 7 days |
| Metformin | Taken | Not taken | N/A | Take twice daily |
| Combigan | Not taken | N/A | Not taken | Take twice daily |