Jnemanichmd.com

Current Medications
Patient Name: __________________________________ Birth date: __________ ►List any current medications you are taking:
Anti Depressant:
Anti Ulcer:
Allergy/Asthma:
 Effexor (venlafaxine)
 Prilosec (omeprazole)
 Allegra (fexofenadine)
 Cymbalta (duloxetine)
 Prevacid (lansoprazole)
 Claritin (loratadine)
 Prozac (fluoxetine)
 Nexium (esomeprazole)
 Singulair (montelukast)
 Paxil (paroxetine)
 Protonix (pantoprazole)
 Zyrtec (cetirizine)
 Wellbutrin (bupropion)
 Tagamet (cimetidine)
 Albuterol Inhaler
 Zoloft (sertraline)
 Zantac (ranitidine)
 Asthma-Steroid Inhaler (any brand)
Blood Thinners:
Cholesterol Lowering:
Diabetes:
 Aspirin
 Lipitor (atorvastatin)
 Insulin Injections (any type)
 Coumadin (warfarin)
 Zocor (simvastatin)
 Glucophage (metformin)
 Refludan (lepirudin)
 Crestor (rosuvastatin)
 DiaBeta, Glynase or Micronase (glyburide)
 Ticlid (ticlopidine)
 Mevacor (lovastatin)
 Glucotrol (glipizide)
 Plavix (clopidogrel)
 Niaspan (niacin)
 Glucagon
 Aggrastat (tirofiban)
 Gemfibrozil
 Avandia (rosiglitazone)
 Integrilin (eptifibatide)
 Precose (acarbose)
Cardiac/Hypertension:
Pain Medications:
Antibiotics:
 Capoten (captopril)
 Darvocet
 Amoxicillin
 Lisinopril
 Fentanyl
 Augmentin (amoxicillin/potassium)
 Cozaar (losartan)
 Hydrocodone
 Bactrim (trimethoprim)
 Diovan (valsartan)
 Biaxin (clarithromycin)
 Dyazide (hydrochlorothiazide)
 MS Contin
 Nifedipine
 Neurontin
 Cleocin (clindamycin)
 Verapamil
 Oxycodone
 Doxycycline
 Diltiazem
 OxyContin
 Erythromycin
 Norvasc (amlodipine)
 Percocet
 Keflex (cephalexin)
 Inderal (propranolol)
 Tylenol #3
 Levaquin (levofloxacin)
 Tenormin (atenolol)
 Vicodin
 Lamisil (terbinafine hydrochloride)
 Lopressor (metoprolol)
 Vistaril
 Sporanox (itraconazole)
 Coreg (carvedilol)
 Zanaflex
 Zithromax (azithromycin)
Anti Inflammatory:
Osteoporosis Treatment:
Reproductive:
 Acetaminophen (Tylenol)
 Actonel
 Birth Control Pills
 Celebrex
 Fosamax
 Depo-Provera Injections
 Naproxen (Aleve)
 Hormone Replacement (estrogen/progestin)
 Ibuprofen
 Prednisone
Other:
 ___________________
 ___________________
 ___________________

Source: http://jnemanichmd.com/pdfs/current_medication.pdf