When you receive this form新患の予約の際に渡されます。訪問前に送付し、自宅で詳細を確認できるようにする医療提供者もあります。薬が変わった際のフォローアップ受診時に更新を求められることもあります。
What to bring or have ready薬のボトルまたは各ラベルの写真、薬局から入手できれば薬リストの印刷物、そして過去のアレルギー反応のメモ（服用した薬と症状の内容を含む）。
現在の服薬 / Current Medications
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Medication name
薬の名前
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.
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.
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).
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.
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').
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.
Select: mild (minor discomfort, no treatment needed), moderate (required treatment such as an antihistamine), or severe (required emergency care or caused anaphylaxis).
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.
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.
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.
Select: mild (minor symptoms that resolved on their own), moderate (required medication or a clinic visit), or severe (required emergency care or caused anaphylaxis).