Free Prescription Medicine List Template
Prescription Medicine List
Patient Information
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Patient Name: Houston Smith
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Date of Birth: January 15, 2050
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Patient ID: 123456
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Contact Information: 222 555 7777
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Date of Prescription: October 8, 2084
Prescriber Information
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Prescriber Name: Dr. [YOUR NAME]
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Prescriber’s Address: [YOUR COMPANY ADDRESS]
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Prescriber’s Contact Information: [YOUR EMAIL]
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License Number: CA-789456
Medication Details
|
Medication Name |
Dosage |
Frequency |
Route of Administration |
Indications |
Refills |
|---|---|---|---|---|---|
|
Amoxicillin |
500 mg |
3 times a day |
Oral |
Bacterial infections |
2 |
|
Metformin |
500 mg |
Twice a day |
Oral |
Type 2 diabetes |
3 |
|
Lisinopril |
20 mg |
Once daily |
Oral |
Hypertension |
0 |
|
Atorvastatin |
10 mg |
Once daily |
Oral |
Hyperlipidemia |
1 |
|
Albuterol Inhaler |
90 mcg |
As needed |
Inhalation |
Asthma or COPD exacerbation |
3 |
Additional Instructions
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Amoxicillin: Take with food to minimize gastrointestinal upset. Complete the full course even if symptoms improve.
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Metformin: Take with meals to reduce the risk of gastrointestinal side effects.
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Lisinopril: Monitor blood pressure regularly and report any significant changes.
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Atorvastatin: Advise a heart-healthy diet alongside medication for optimal results.
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Albuterol Inhaler: Shake well before use. Use 2 puffs as needed for shortness of breath.
Patient Notes
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Allergies: Penicillin
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Current Medications: Aspirin 81 mg once daily
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Medical History: Hypertension, Type 2 Diabetes
Follow-Up Appointment
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Date: November 15, 2084
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Time: 10:00 AM
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Purpose: Routine check-up
Prescriber Signature:
Date: October 8, 2055
