Medication details

Name

Enter the name of the medication this person is taking now or has received in the past. You can enter up to 90 characters. This field is required.

Dosage

Enter the amount the person takes (or took) and how often (for example, 50 mtg three times daily). You can enter up to 100 characters.

Medication Required Daily

Select Yes, No, or Unknown to indicate whether the person must take the medication each day. This field is required.

Prescribed By

Enter the name of the physician who prescribed this medication. You can enter up to 90 characters.

Refills Prescribed

Enter the number of refills that were prescribed. You can enter up to 50 characters.

Date Prescribed

Enter the date on which this medication was prescribed. Use the format MM/DD/YYYY.  This field is required.

Discontinued Date

If the person no longer takes this medication, enter the date the person stopped taking it. Use the format MM/DD/YYYY.

Notes

Enter a reason for taking medication, any reactions to the medication, any misuse or inconsistency in the use of the medication, and so on. You can enter up to 500 characters.

Pharmacy Name

Enter the name of the pharmacy the person uses to fill this prescription. You can enter up to 90 characters.

Location Details

Enter the pharmacy's address or describe its location. You can enter up to 100 characters.

Phone

Enter the 10-digit phone number of the pharmacy.

Ext

Enter the pharmacy's telephone extension, if any. You can enter up to five digits.

Fax

Enter the 10-digit fax number of the pharmacy.