Prescription Medication Record
Prescription Medication Record
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 |
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 |
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 |
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.
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. |
Allergies
|
Allergen |
Reaction |
|---|---|
|
Penicillin |
Rash |
|
Peanuts |
Anaphylaxis |
Monitoring and Follow-Up
-
Blood pressure check: Every two weeks.
-
Kidney function tests: After 30 days of use.
-
Follow-up appointment: September 25, 2055.
Notes
-
Patient has a history of hypertension.
-
Recommended to avoid potassium-rich foods while on this medication.
-
Avoid alcohol consumption during the medication period.
Prescribing Physician’s Signature
|
Field |
Details |
|---|---|
|
Physician’s Signature |
|
|
Date |
August 20, 2085 |
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].
