
Patient Medication History Form This form can also be found at www. uwmedicationlist. org The medicines you take are part of your health information. Please fill out this form or have your caregiver complete it and discuss it with your medical provider. If you need more space to list your medicines ask for another form. Please do not write on the back of this form. Patient Name Page Allergies Name of Substance drug or food Type of Reaction Check if none Do you react to latex or rubber gloves balloons etc with a rash wheezing etc. For female patients ONLY Are you currently pregnant Are you considering becoming pregnant Yes No Current Medications Prescription Drugs Strength Directions such as 2 tablets in the a.m. Prescribed By such as eye drops creams such as 50 mg Check box if taken only as needed. such as John Doe MD Over-the-Counter Medications such as aspirin Herbs Vitamins Minerals Etc. such as St. John s Wort STAFF ONLY Pharmacy Name PT. NO NAME DOB Phone Medication list reviewed ....
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How to fill out the UH2301 online
The UH2301 form, also known as the Patient Medication History Form, is essential for communicating your medication details to your healthcare provider. This guide will assist you in filling out the form accurately and completely.
Follow the steps to successfully complete the form
- Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
- Begin by filling in your name at the top of the form. Ensure that your name is clearly written for accurate identification.
- Proceed to the allergies section. Indicate any known allergies by entering the name of the substance and specifying the type of reaction. If there are no allergies, check the box that indicates none.
- Answer the latex allergy question. Indicate whether you react to latex or rubber with a rash or wheezing.
- For female patients, respond to the questions regarding pregnancy and breastfeeding. Carefully mark yes or no as applicable.
- Move on to the current medications section. List any prescription drugs you are currently taking, including the strength, directions for use, and the name of the prescribing provider.
- Check the box if you take any prescription medication only as needed. If you have no current medications, check the box indicating none.
- Next, fill in the over-the-counter medications section if applicable. Specify the medication, its strength, and directions for use.
- Repeat the previous step for any herbs, vitamins, or minerals you take. Ensure you indicate strength and directions for usage.
- Complete the staff-only section by entering the pharmacy name if applicable.
- Review your completed form to ensure all information is correct and legible.
- Once all sections are filled out, you can save the changes, download the form, print it for your records, or share it with your healthcare provider.
Complete your UH2301 form online today to streamline your healthcare experience.
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