HomeMy WebLinkAboutDrug List FormName: _______________________________________ Date: ____________________
Prescription Drug List
List one drug per row; do not include over-the-counter medicines
PLEASE CHECK SPELLING AND PRINT LEGIBLY
Brand or
Generic?
Dosage
E.g. mg, mcg, %
Frequency
E.g. 1 pill/day
1 bottle/month
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
----------------------------------------------------------------------------------------------------------
Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
----------------------------------------------------------------------------------------------------------
Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
----------------------------------------------------------------------------------------------------------
Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Drug Name:
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Circle one: Tablet, Capsule, Caplet, Powder, Patch, Cream, Lotion,
Liquid, Syrup, Suspension, Spray, Mist, Drops
Inhalers
Dosage
E.g. 6.7 gm
8.76 gm
Package size
E.g. 1 inhaler, box of #
aerosols, blister pack of 14
Frequency
E.g. 1 inhaler/month
1 box/month
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Injections Pens/Vials
# per package
Size
E.g. 3 ml vial, 3 ml pen
Amount
How many do you
use each month?
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
Drug Name:
If more space is needed, attach a list of additional drugs, inhalers, and injections. Please include all the details
requested above for each drug, including dosage, size, frequency, brand or generic, etc.
SHIIP is a free, unbiased counseling program provided by the State of Iowa Insurance Division. This form
contains confidential information, and we will not share it with anyone other than you r SHIIP counselor(s).