Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formAt any new-patient appointment. Some providers send it before your visit so you can look up details at home. You may also be asked to update it at follow-up visits when medications change.
What to bring or have readyYour pill bottles or a photo of each label; a printout of your medication list from your pharmacy if available; and a note of any past allergic reactions, including what you took and what happened.
Current Medications
English
What this field means
Medication name
Write the brand name and/or generic name — for example, 'Lipitor (atorvastatin).' Include both prescription and over-the-counter medications you take on a regular basis.
Dose
The amount in each tablet, capsule, or dose — for example, '10 mg' or '500 mg.' Check the pill bottle label if you are not sure.
Frequency (how often)
How often you take the medication — for example, 'once daily,' 'twice daily,' 'as needed,' or 'every 8 hours.' Use the wording on your prescription label.
Route (how it is taken)
How you take the medication. Common options: oral (swallowed), injected (such as insulin), inhaled (asthma inhaler), topical (applied to skin), or under the tongue (sublingual).
Prescribing provider
The name of the doctor or provider who prescribed this medication. If it is an over-the-counter product you chose yourself, write 'self' or 'OTC.'
Vitamins and Supplements
English
What this field means
Supplement or vitamin name
Include herbal supplements, vitamins, protein powders, and any other products you take regularly, even if they are sold as food. Some can interact with medications or affect test results.
Dose or amount taken
The amount per serving or per capsule — for example, '1000 mg vitamin C' or '1 scoop protein powder (30 g).' Check the product label.
How often taken
For example: 'daily,' 'once a week,' or 'with meals.' Providers need this to spot potential interactions with your other medications.
Drug Allergies
English
What this field means
Substance you are allergic to
List the medication name — for example, 'penicillin,' 'sulfa drugs,' or 'aspirin.' If you are unsure of the exact drug, describe it as best you can (for example, 'a red antibiotic capsule').
Reaction type
Describe what happens when you take this substance — for example: rash, hives, itching, swelling, difficulty breathing, anaphylaxis, nausea, or vomiting. Knowing the reaction type helps providers choose safe alternatives.
Severity
Select: mild (minor discomfort, no treatment needed), moderate (required treatment such as an antihistamine), or severe (required emergency care or caused anaphylaxis).
Confirmed by allergy test
Select yes if a provider formally tested you (such as a skin prick test or blood test). Select no if the allergy was identified only from a past reaction. Either answer is useful — providers treat reported reactions seriously regardless.
Food and Other Allergies
English
What this field means
Food or other substance
Common examples include shellfish, tree nuts, peanuts, latex, bee stings, and contrast dye used in imaging scans. Food allergies can affect which medications or IV fluids are safe for you.
Reaction that occurs
Describe what happens — for example: hives, swelling of the lips or throat, stomach cramps, vomiting, or difficulty breathing. Be as specific as possible so the care team can plan ahead.
Severity
Select: mild (minor symptoms that resolved on their own), moderate (required medication or a clinic visit), or severe (required emergency care or caused anaphylaxis).