Printable List for Drugs Currently Taking : Gastroenterology Consultants of South Jersey

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

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