For Additional Space, Use Back of Form

Page 4 of 4 PRS, INC.

MEDICATION FORM

Date Ordered / Name of Drug / Route / Strength /

Schedule

/

Date of D/C

For additional space, use back of form.

Who is responsible for dispensing client’s medication? Self Other please specify

Is there Current or Historical Evidence of Substance Abuse by Client? Yes No

Or Family? Yes No

Comments:

Please list client’s history of allergies, idiosyncratic and/or other adverse reactions to drugs and/or foods:

List other medications client is currently taking, including non-prescription meds:

What is the history of medication compliance?

List client’s history of chemotherapy:

Most Effective:

Least Effective:

Date: Signature of Licensed Mental Health Provider or Physician: