MEDICAL SUPPLEMENT Name _______________________________________ Date ______________________________ Are you presently being treated for medical problems? ⃝ Yes ⃝ No If yes, for what problem and who is treating you?__________________________________________________ ___________________________________________________________________________________________ When was your last physical examination?______________________________________________________________ Where and by whom?_________________________________________________________________________ List all medications you are currently taking, including over the counter and herbal/natural preparations: Medication Dosage Why do you take it? Who prescribes? 1 1000 Darrington Drive, Suite 204, Cary, North Carolina 27513 | (P) 919.338.5620 | (F) 919.336.4519 | [email protected] MEDICAL SUPPLEMENT Do you have any drug, food, or environmental allergies? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you had any bad drug reactions? Please describe. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please list any surgeries: Date ___________________Surgery For ___________________________________________ Date ___________________Surgery For ___________________________________________ Date ___________________Surgery For ___________________________________________ (Women Only) Reproductive History: When was your last menstrual period? __________________________________ Do you currently use birth control? ⃝ Yes ⃝ No If yes, what kind? Any problems? ______________________________________________________________________________ Are you currently pregnant? ⃝ Yes ⃝ No Are you trying to become pregnant? ⃝ Yes ⃝ No 2 1000 Darrington Drive, Suite 204, Cary, North Carolina 27513 | (P) 919.338.5620 | (F) 919.336.4519 | [email protected] MEDICAL SUPPLEMENT What medications have you been treated with? (Check all that apply) (Put a C beside current medications) Abilify (Aripiprazole) Duragesic (Fentanyl) Miralax (Polyethylene glycol) Adderall (Dextroamphetamine- Amphetamine) Effexor (Venlafaxine) Motrin (Ibuprofen) Aleve (Naproxen) Elavil (Amitriptyline) Movantik (Naloxegol) MS Contin (Morphine Sulfate Ambien (Zolpidem) Eskalith (Lithium Carbonate) Controlled Release) NAC, Cetylev, Acetadote (N- Amrix (Cyclobenzaprine ER) Ex-Lax, Senokot (Senna glycoside) acetylcysteine) Antabuse (Disulfiram) Flexeril (Cyclobenzaprine) Neurontin (Gabapentin) Aricept (Donepezil) Focalin (dexmethylphenidate) Norpramin (Despramine) Atarax, Vistaril (Hydroxyzine) Gabatril (Tiagabine) Nucynta (Tapentadol) Ativan (Lorazepam) Geodon (Ziprasidone) Nuvigil (Armodafinil) Avinza, Kadian (Morphine) Haldol (Haloperidol) Opana (Oxymorphone) Buspar (Buspirone) Hydrocodone (Lortab) Oxycodone (Percocet) Inderal (Propranolol or a Butrans patch different Beta Blocker (drug (Buprenorphine) ending in -lol)) Pamelor (Nortriptyline) Campral (Acamprosate) Keppra (Levitiraetam) Paxil (Paroxetine) Cataflam (Diclofenac) Ketamine (Ketamine) Phenobarbitol Catapres (Clonidine) Klonopin (Clonazpam) Pristiq (Desvenlafaxine) CBD oil/supplement (Cannabidiol) Lamictal (Lamotrigine) Provigil (Modafinil) Celexa (Citalopram) Latuda (Lurasidone) Prozac (Fluoxetine) Clozaril (Clozapine) Lexapro (Escitalopram) Remeron (Mirtazapine) Cogentin (Benztropine) Librium (Chlordiazepoxide) Restoril (Temazepam) Colace (Docusate sodium) Lidoderm patch (Lidocaine) Risperdal (Risperidone) Concerta, Ritalin (methylphenidate) Lioresal (Baclofen) Roxicet (Roxicet) Cymbalta (Duloxetine) Lithium Serax (Oxazepam) Depakote (Valporic Acid) Loxitane (Loxapine) Seroquel (Quetiapine) Desyrel (Trazodone) Lunesta (Eszopiclone) Sinequan (Doxepin) Dexedrine (Dextroamphetamine) Luvox (Fluvoxamine) Skelaxin (Metaxalone) Dilantin (Pheytoin) Lyrica (Pregablin) Soma (Carisoprodol) Dilaudid (Hydromorphone) Melatonin Sonata (Zaleplon) Ducolax (Bisacodyl) Methadone Spravato (Esketamine) Medications are continued on next page. 3 1000 Darrington Drive, Suite 204, Cary, North Carolina 27513 | (P) 919.338.5620 | (F) 919.336.4519 | [email protected] MEDICAL SUPPLEMENT What medications have you been treated with? (Check all that apply) (Put a C beside current medications) Strattera (Atomoxetine) Valium (Diazepam) Zonegran (Zonisamide) Sublocade (buprenorphine injection) Viibryd (Vilazodone) Zyprexa (Olanzapine) Suboxone / Subutex (Buprenorphine) Vivitrol, Revia (Naltrexone) Tegretol (Arbamazepine) Voltaren Gel (Diclofenac Gel) Ashwagandha Thorazine (Chlorpromazine) Voltaren tablet (Diclofenac) Butterbur/Feverfew Tofranil (Imipramine) Vraylar (Cariprazine) Inositol Topamax (Topiramate) Vyvanse (Lisdexamfetamine) Rhodiola rosea Tramadol (Ultracet) Wellbutrin, Zyban (Bupropion) St Johns Wort Trileptal (Oxcarbazepine) Xanax (Alprazolam) Valerian Root Trintellix, Brintellix (Vortioxetine) Zanaflex (Tizanadine) Ultram (Tramadol) Zoloft (Sertraline) Which of these medications were particularly helpful or problematic? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Is there anything else you would like for your provider to know? __________________________________________________________________________________________________ __________________________________________________________________________________________________ 4 1000 Darrington Drive, Suite 204, Cary, North Carolina 27513 | (P) 919.338.5620 | (F) 919.336.4519 | [email protected] .