Prescription Medication Record

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This document is designed to keep track of prescribed medications for individuals to ensure proper usage, monitoring, and compliance with medical instructions.

Patient Information

Field	Details
Patient Name	Franz Davis
Date of Birth	April 15, 2050
Address	Charleston, SC 29401
Contact Number	222 555 7777
Medical Record Number	MR1234567890

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Prescribing Physician Information

Field	Details
Physician Name	[YOUR NAME]
License Number	MD1234567890
Clinic/Hospital Name	[YOUR COMPANY NAME]
Address	[YOUR COMPANY ADDRESS]
Contact Number	222 555 7777
Date of Prescription	August 20, 2085

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Medication Details

Medication Name	Lisinopril
Dosage	20 mg
Form	Tablet
Frequency	Once daily
Duration	30 days
Refills	2
Start Date	August 20, 2085
End Date	September 19, 2085

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Instructions for Use

• Take one tablet by mouth daily, preferably at the same time each day.

• May be taken with or without food.

• Do not miss doses; if missed, take as soon as remembered unless it is close to the time for the next dose.

• If more than one dose is missed, consult the physician.

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Possible Side Effects

Side Effect	Severity	Actions
Dizziness	Mild	Rest and hydrate. Contact physician if persistent.
Cough	Mild	May subside with continued use. Contact physician if severe.
Low Blood Pressure	Moderate	Monitor blood pressure regularly. Consult physician if it drops significantly.

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Allergies

Allergen	Reaction
Penicillin	Rash
Peanuts	Anaphylaxis

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Monitoring and Follow-Up

• Blood pressure check: Every two weeks.

• Kidney function tests: After 30 days of use.

• Follow-up appointment: September 25, 2055.

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Notes

• Patient has a history of hypertension.

• Recommended to avoid potassium-rich foods while on this medication.

• Avoid alcohol consumption during the medication period.

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Prescribing Physician’s Signature

Field	Details
Physician’s Signature
Date	August 20, 2085

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This Prescription Medication Record serves as a formal document to manage and track medications prescribed by [YOUR COMPANY NAME]. For any questions or concerns, contact [YOUR NAME] at [YOUR EMAIL].

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