Medication and Allergy Worksheet - Moffitt
Medication and Allergy Worksheet
Instructions: In addition to the questionnaire you will complete online or on the computer in our office, we need to get a complete list of your allergies and medications. We review and update your medication list each time you come to see a provider at Moffitt. Please complete this worksheet at home and bring it with you to your appointment.
Allergies: Please list all things that you are allergic to including medications, foods, x-ray dyes, and iodine.
For each item, include a description of the reaction you have to it. I have no known allergies.
Source of allergy
Reaction
Medications: Please list ALL prescription and over-the-counter medications (drugs) including eye drops,
topical patches, and injections (including vitamins and herbal products) you are taking or receive.
I am not taking any medications.
How often is the
Route (pill, medication used or
# of injection, taken? (times per
Date Reason for Duration or
Name of medication Strength tablets etc.)
day/week/month)
started
using
Stop date?
Worksheet Only ? Not for Scanning
Patient Name: _____________________________ Date Of Birth: _____________________________
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