Pondworks Psychiatry & Psychotherapy

Pondworks Medications List

Please list all medications you have taken. Start with medications you are currently taking. If you take more than eight medications, please submit more than one form.

Name * Date of birth * How many medications do you currently take?

Medication #1

Medication #1 name (ex: Lexapro) Who prescribes it? (ex: Dr. John Doe) How much? (ex: 20mg) How to use? (ex: 1 time daily) Start date (ex: 04/04) Stop date (ex: 05/05) Reason for stopping or why I'm taking it (ex: too sleepy)

Medication #2

Medication #2: name Medication #2: who prescribes it? Medication #2: how much? Medication #2: how to use? Medication #2: start date Medication #2: stop date Medication #2: reason for stopping or why I'm taking it

Medication #3

Medication #3: name Medication #3: who prescribes it? Medication #3: how much? Medication #3: how to use? Medication #3: start date Medication #3: stop date Medication #3: reason for stopping or why I'm taking it

Medication #4

Medication #4: name Medication #4: who prescribes it? Medication #4: how much? Medication #4: how to use? Medication #4: start date Medication #4: stop date Medication #5: reason for stopping or why I'm taking it

Medication #5

Medication #5: name Medication #5: who prescribes it? Medication #5: how much? Medication #5: how to use? Medication #5: start date Medication #5: stop date Medication #5: reason for stopping or why I'm taking it

Medication #6

Medication #6: name Medication #6: who prescribes it? Medicine #6: how much? Medication #6: how to use? Medication #6: start date Medication #6: stop date Medication #6: reason for stopping or why I'm taking it

Medication #7

Medication #7: name Medication #7: who prescribes it? Medication #7: how much? Medication #7: how to use? Medication #7: start date Medication #7: stop date Medication #7: reason for stopping or why I'm taking it

Medication #8

Medication #8: name Medication #8: who prescribes it? Medication #8: how much? Medication #8: how to use? Medication #8: start date Medication #8: stop date Medication #8: reason for stopping or why I'm taking it Is this list complete? *