2 Week Medication Usage History

Two Week Medication Usage History

Attachment 14

2-week Medication Usage History

STAFF ID:__ __ __ Please list ALL medications (including prescription drugs, over the counter drugs, dietary supplements (including vitamins), herbal, homeopathic and health food preparations) taken routinely or in the last 2 weekss.
 □ Please check this box if patient has not taken any medications in the last 2 weeks.
	Currently taking medication?	Discont’d?	Medication Name	Dosage	Route of Admin.	Dosing Frequency	Reason for taking	Date Last Taken
1	YES NO	YES NO
2	YES NO	YES NO
3	YES NO	YES NO
4	YES NO	YES NO
5	YES NO	YES NO
6	YES NO	YES NO
7	YES NO	YES NO
8	YES NO	YES NO
9	YES NO	YES NO
10	YES NO	YES NO

	Currently taking medication?	Discontinued?	Medication Name	Dosage	Route of Administration	Dosing Frequency	Reason for taking	Date Last Taken
11	YES NO	YES NO
12	YES NO	YES NO
13	YES NO	YES NO
14	YES NO	YES NO
15	YES NO	YES NO
16	YES NO	YES NO
17	YES NO	YES NO
18	YES NO	YES NO
19	YES NO	YES NO
20	YES NO	YES NO

	Currently taking medication?	Discontinued?	Medication Name	Dosage	Route of Administration	Dosing Frequency	Reason for taking	Date Last Taken
21	YES NO	YES NO
22	YES NO	YES NO
23	YES NO	YES NO
24	YES NO	YES NO
25	YES NO	YES NO
26	YES NO	YES NO
27	YES NO	YES NO
28	YES NO	YES NO
29	YES NO	YES NO
30	YES NO	YES NO

Abbreviation	Meaning
Qhs	every night at bedtime
bid	twice a day
tid	3x a day
qid	4x a day
qam	every morning
qpm	every evening