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Current Medications
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Please list all medications you are currently taking.
I am NOT currently taking any medications or supplements
PSYCHOLOGICAL/NEUROLOGICAL
Adderall
Diazepam
Prozac
Amitriptyline
Effexor
Trazadone
Celexa
Fluoxetine
Wellbutrin
Cymbalta
Lexapro
Xanax
Zoloft
HEART
Amlodipine Besylate
Coumadin
Metoprolol Tartrate
Atenolol
Cozaar
Nitrostat
Carvdilol
Diovan
Norvasc
Clonidine
Lisinopril
Plavix
Clopidogrel Bisulfate
Losartan Potassium
Toprol
Warfarin
CHOLESTEROL
Atorvastatin
Lovastatin
Pravastatin Sodium
Crestor
Simvastatin
Zetia
Lipitor
Pravachol
Zocor
ACID REFLUX
Aciphex
Nexium
Omeprazole
Pantoprazole Sodium
Prevacid
Prilosec
Protonix
ALLERGY/ASTHMA
Advair
Claritin
Nasonex
Albuterol
Flonase
Proair
Allegra
Fluticasone Propionate
Singulair
Benadryl
Loratadine
Zyrtec
DIABETES
Glipizide
Lantus
Metformin
Novolog
ANTIBIOTIC
Amoxicillin
Cephalexin
Sulfamethoxazole
SUPPLEMENTS
Multi-Vitamin
Vitamin C
CoQ10
Calcium
Vitamin D
Glucosamine
Folic Acid
Vitamin D3
Iron
Vitamin B Complex
Vitamin E
Magnesium
Vitamin B3 (Niacin)
Omega 3
Potassium
Vitamin B12
Fish Oil
Probiotics
THYROID
Levothyroxine Sodium
Synthroid
Thyroid
REPRODUCTIVE/MENOPAUSE
Estradiol
Premarin
WATER PILL
Furosemide
Hydrochlorothiazide
Lasix
Spironolactone
NAUSEA
Ondansetron
Promethazine
Phenergan
SLEEP
Ambien
Zolpidem
ANTI-INFLAMMATORY
Advil
Diclofenac Sodium
Mobic
Aleve
Etodolac
Naproxen
Aspirin
Ibuprofen
Prednisone
Baby Aspirin
Meloxicam
Tylenol
Celebrex
Methylprednisolone
PAIN/MUSCLE RELAXANT
Baclofen
Hydrocodone
(with Acetaminophen)
Soma
Carisoprodol
Metaxalone
Tizanidine
Codeine
(with Acetaminophen)
Norco
Tramadol
Cyclobenzaprine
Oxycodone
(with Acetaminophen)
Ultram
Flexeril
Percocet
NERVE PAIN
Gabapentin
Lyrica
Neurontin
OTHER
Allopurinol
Finasteride
Plaquenil
ADDITIONAL MEDICATIONS NOT LISTED ABOVE:
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