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Gastroenterology Consultants of South Jersey
Amherst Commons, Building A, Suite 2
693 Main Street, Lumberton, New Jersey
Telephone: (609) 265-1700    Visit us Online: www.GCSJ.org

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LIST OF DRUGS CURRENTLY TAKING

 
  

Patient Name: ______________________________________________ Date: __________________

Patient : Please print and fill-in the following. Write the information as found on your bottle labels.

PRESCRIPTIONS TAKING:

NAME OF DRUG

DOCTOR

ALIMENT

HOW OFTEN

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

VITAMINS OR HERBS TAKING:

NAME OF VITAMIN/HERB

RECOMMENDED BY

ALIMENT

HOW OFTEN

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

  

 

 

 

 

 

 

 

 

   

ALLERGIES TO:

MEDICATION NAME

WHAT HAPPENS

DATE OF LAST OCCURRENCE

 

 

 

 

 

 

 

 

 

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Copyright 2005 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.
 

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