Medical History - Medications and Allergies

Medical Assessment - Medications and Allergies
(Form 6 of 6)

Name

Date of Birth

Form Entry Date

CURRENT: Medications You Are Now Taking
(including any over the counter medications, hormones and birth control pills):

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

Drug

Dosage

Frequency

PAST: Have you ever used any of the following medications on a regular basis?
(If ‘YES’, when, and did it work?)

Aspirin-containing medications
(Goodies, Excedrin, Aspirin, Alka-Selzer)

Yes No

Details

Arthritis Medications
(Nsaids, Motrin, Ibuprofen, Advil, Aleve, etc.)

Yes No

Details

Ulcer medications
(Prilosec, Prevacid, Aciphex, Tagamet, Protonix, Nexium)

Yes No

Details

Stomach cramps medication
(Librax, Levsin, Donnatal, Hyoscyamine, Bentyl, NuLev, Zelnorm)

Yes No

Details

Nerve Pills
(Xanax, Valium, Tranxene, Prozac, Zoloft, Paxil, etc.)

Yes No

Details

Blood thinners
(Coumadin, Aspirin, Heparin, Xarelto, Plavix, Eliquis etc.)

Yes No

Details

Anti Nausea medicines
(Phenergan, Zofran, Compazine)

Yes No

Details

Iron tablets

Yes No

Details

Laxatives
(Correctol, Senokot, Lactulose, Miralax, Kristalose, etc.)

Yes No

Details

Herbal Product (Please specify product)

Yes No

Details

Medication to help stomach empty faster
(Reglan, Propulsid, etc.)

Yes No

Details

Fiber supplements
(Metamucil, Fiber-Con, Citrucel, Konsyl, Equalactin)

Yes No

Details

Diet pills (Prescription or over-the-counter)
Please specify product

Yes No

Details

Antacids
(Tums, Rolaids, etc.)

Yes No

Details

Questran powder, Cholestid, Welchol

Yes No

Details

Imodium, Lomotil or Pepto Bismol (for diarrhea)

Yes No

Details

Asacol, Pentasa, Prednisone, Imuran, Purinethol, Methotrexate, Infliximab, Entyvio, Simponi, Humira, etc

Yes No

Details

Accutane

Yes No

Details

List pain medications you’ve used in the past

Allergies
(Including medications, x-ray dye, latex, tapes, foods, etc.)

Please list all allergies

Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677

HealthGrades.com

Check out our exceptional ratings and leave your own reviews of Dr. Goodman.

More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to info@goodman-gi.com.

Medical Assessment - Medications and Allergies(Form 6 of 6)

CURRENT: Medications You Are Now Taking (including any over the counter medications, hormones and birth control pills):

PAST: Have you ever used any of the following medications on a regular basis? (If ‘YES’, when, and did it work?)

Allergies(Including medications, x-ray dye, latex, tapes, foods, etc.)

Our Location

HealthGrades.com

More Info

Medical Assessment - Medications and Allergies
(Form 6 of 6)

CURRENT: Medications You Are Now Taking
(including any over the counter medications, hormones and birth control pills):

PAST: Have you ever used any of the following medications on a regular basis?
(If ‘YES’, when, and did it work?)

Allergies
(Including medications, x-ray dye, latex, tapes, foods, etc.)