New Client List of Medications

Today's Date:
Name of Person Completing this Form:

Client Details

Client First and Last Name:
Address, City, Zip:
Date of Birth:
Cell Phone Number:
Your Email: (You will be emailed a copy of this form with the email provided here)
Gender:MaleFemaleOther

Other:

Caregiver First and Last Name:

Medication Details

Note: (One medication set is only for one medication)
List all vitamins and over the counter herbs taking on this form as well, including diabetic medication, lotions, creams, eye drops, etc.

Set No 1:

Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 2 to enter more details if have an other medication:

Set No 2:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 3 to enter more details if have an other medication:

Set No 3:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 4 to enter more details if have an other medication:

Set No 4:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 5 to enter more details if have an other medication:

Set No 5:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 6 to enter more details if have an other medication:

Set No 6:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 7 to enter more details if have an other medication:

Set No 7:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 8 to enter more details if have an other medication:

Set No 8:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 9 to enter more details if have an other medication:

Set No 9:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 10 to enter more details if have an other medication:

Set No 10:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 11 to enter more details if have an other medication:

Set No 11:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 12 to enter more details if have an other medication:

Set No 12:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 13 to enter more details if have an other medication:

Set No 13:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 14 to enter more details if have an other medication:

Set No 14:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 15 to enter more details if have an other medication:

Set No 15:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 16 to enter more details if have an other medication:

Set No 16:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 17 to enter more details if have an other medication:

Set No 17:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 18 to enter more details if have an other medication:

Set No 18:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 19 to enter more details if have an other medication:

Set No 19:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 20 to enter more details if have an other medication:

Set No 20:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 21 to enter more details if have an other medication:

Set No 21:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 22 to enter more details if have an other medication:

Set No 22:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 23 to enter more details if have an other medication:

Set No 23:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 24 to enter more details if have an other medication:

Set No 24:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 25 to enter more details if have an other medication:

Set No 25:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 26 to enter more details if have an other medication:

Set No 26:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 27 to enter more details if have an other medication:

Set No 27:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 28 to enter more details if have an other medication:

Set No 28:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 29 to enter more details if have an other medication:

Set No 29:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 30 to enter more details if have an other medication:

Set No 30:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 31 to enter more details if have an other medication:

Set No 31:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 32 to enter more details if have an other medication:

Set No 32:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 33 to enter more details if have an other medication:

Set No 33:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 34 to enter more details if have an other medication:

Set No 34:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 35 to enter more details if have an other medication:

Set No 35:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 36 to enter more details if have an other medication:

Set No 36:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 37 to enter more details if have an other medication:

Set No 37:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 38 to enter more details if have an other medication:

Set No 38:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 39 to enter more details if have an other medication:

Set No 39:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 40 to enter more details if have an other medication:Set No 40

Set No 40:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 41 to enter more details if have an other medication:Set No 41

Set No 41:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 42 to enter more details if have an other medication:Set No 42

Set No 42:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 43 to enter more details if have an other medication:Set No 43

Set No 43:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 44 to enter more details if have an other medication:Set No 44

Set No 44:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 45 to enter more details if have an other medication:Set No 45

Set No 45:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 46 to enter more details if have an other medication:Set No 46

Set No 46:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 47 to enter more details if have an other medication:Set No 47

Set No 47:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 48 to enter more details if have an other medication:Set No 48

Set No 48:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 49 to enter more details if have an other medication:Set No 49

Set No 49:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

Check here for open Set No 50 to enter more details if have an other medication:Set No 50

Set No 50:
Medication Name: (Brand or Generic Name)
Dosage:
Frequency & Route:
Reason for Taking: (High Blood Pressure, Diabetes, Pain, etc.)
Month and Year: (Started Medication)

List Additional Medications, Dosage, Routes Times:

Client Signature:
Caregiver's Printed Name:
Caregiver's Signature:

Electronic Signature Disclaimer

Please ensure all information is correct before hitting Submit, as this is a Legal Document, and may be used in legal proceedings. Your signature is made with intent, and by signing your name electronically to this New Client Current List of Medications, you are agreeing that your signature is the legal equivalent of your manual signature. If you want to opt out of the online New Client Current List of Medications, or any other online form, please contact the office and paper forms will be sent to you.

Check bellow to acknowledge that you have read the Electronic Signature Disclaimer above:
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New Client List of Medications

Client Details

Medication Details

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