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I agree not to take any over-the-counter medicines without approval from my pharmacist.

If you disagree, please explain why I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant.

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Please list all current medical conditions. Choose "None" if none

Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.

Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose "None" if none.

Please list all past or present allergies including allergies to any medications. Choose "None" if none.

Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none.

Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. (This cannot be left blank. )

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