When you receive this form在任何初诊预约时。一些提供者会在您就诊前发送，以便您在家查阅详细信息。当药物发生变化时，您在后续就诊时也可能被要求更新它。
What to bring or have ready您的药瓶或每个标签的照片；如果有，请带上药房提供的药物清单打印件；以及任何过去过敏反应的记录，包括您服用的药物和发生的情况。
当前用药 / Current Medications
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Medication name
药物名称
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.
写明品牌名称和/或通用名称——例如「立普妥（阿托伐他汀）」。包括您定期服用的处方药和非处方药。
Dose
剂量
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.
每片、每粒胶囊或每次剂量的量——例如「10毫克」或「500毫克」。如果不确定，请查看药瓶标签。
Frequency (how often)
频率（多久服一次）
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).
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.'
开具该药处方的医生或医疗提供者姓名。如果是您自行选购的非处方药品，请写「自购」或「OTC」。
维生素与补充剂 / Vitamins and Supplements
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Supplement or vitamin name
补充剂或维生素名称
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.
The amount per serving or per capsule — for example, '1000 mg vitamin C' or '1 scoop protein powder (30 g).' Check the product label.
每份或每粒胶囊的量——例如「维生素C 1000毫克」或「蛋白粉1勺（30克）」。请查看产品标签。
How often taken
服用频率
For example: 'daily,' 'once a week,' or 'with meals.' Providers need this to spot potential interactions with your other medications.
例如：「每日」、「每周一次」或「随餐服用」。医疗提供者需要这些信息来发现与其他药物的潜在相互作用。
药物过敏 / Drug Allergies
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Substance you are allergic to
您过敏的物质
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).