Prescription Medication Record
This document is designed to keep track of prescribed medications for individuals to ensure proper usage, monitoring, and compliance with medical instructions.
Patient Information
Field | Details |
|---|
Patient Name | Franz Davis |
Date of Birth | April 15, 2050 |
Address | Charleston, SC 29401 |
Contact Number | 222 555 7777 |
Medical Record Number | MR1234567890 |
Prescribing Physician Information
Field | Details |
|---|
Physician Name | [YOUR NAME] |
License Number | MD1234567890 |
Clinic/Hospital Name | [YOUR COMPANY NAME] |
Address | [YOUR COMPANY ADDRESS] |
Contact Number | 222 555 7777 |
Date of Prescription | August 20, 2085 |
Medication Details
Medication Name | Lisinopril |
|---|
Dosage | 20 mg |
Form | Tablet |
Frequency | Once daily |
Duration | 30 days |
Refills | 2 |
Start Date | August 20, 2085 |
End Date | September 19, 2085 |
Instructions for Use
Take one tablet by mouth daily, preferably at the same time each day.
May be taken with or without food.
Do not miss doses; if missed, take as soon as remembered unless it is close to the time for the next dose.
If more than one dose is missed, consult the physician.
Possible Side Effects
Side Effect | Severity | Actions |
|---|
Dizziness | Mild | Rest and hydrate. Contact physician if persistent. |
Cough | Mild | May subside with continued use. Contact physician if severe. |
Low Blood Pressure | Moderate | Monitor blood pressure regularly. Consult physician if it drops significantly. |
Allergies
Allergen | Reaction |
|---|
Penicillin | Rash |
Peanuts | Anaphylaxis |
Monitoring and Follow-Up
Blood pressure check: Every two weeks.
Kidney function tests: After 30 days of use.
Follow-up appointment: September 25, 2055.
Notes
Patient has a history of hypertension.
Recommended to avoid potassium-rich foods while on this medication.
Avoid alcohol consumption during the medication period.
Prescribing Physician’s Signature
Field | Details |
|---|
Physician’s Signature | 
|
Date | August 20, 2085 |
This Prescription Medication Record serves as a formal document to manage and track medications prescribed by [YOUR COMPANY NAME]. For any questions or concerns, contact [YOUR NAME] at [YOUR EMAIL].
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