Before you complete the form, please follow these instructions:

1) Only list PRESCRIPTION medications that you take regularly or soon plan to be taking regularly

2) If you take a specific brand, please enter the Name Brand, otherwise enter the generic name.

3) List the dosage of each medication (such as 50 mg or 200 mg)

4) List the frequency of each medication (such as 2 pills twice a day, or 1 pill per day)

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An example of a prescription medication entry would look like this:

1) Simvastatin, 10mg, 2 per day

2) Lisinopril, 20mg, 1 per day

3) Synthroid (name brand), 75mcg, 1 per day

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