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Daryl's WLS Bulletin
Medication List

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Personal Medication Record

medications you               medications you                       medications you have

take every day:                  you take periodically:              taken in the past:

--------------------------         ------------------------------           ------------------------------

Medication Name             Medication Name                     Medication Name

--------------------------          -----------------------------              ----------------------------

Rx / Non-Rx                        Rx / Non-Rx                                Rx / Non-Rx

date & doctor                    date & doctor                             date & doctor

--------------------------         ----------------------------                 -----------------------------

Dosage                                Dosage                                         Dosage

---------------------------         ---------------------------                   ----------------------------

Purpose                               Purpose                                       Purpose

---------------------------          --------------------------                  -----------------------------

How Taken                         How Taken                                  How Taken

(with / without food)         (with / without food)                (with / without food)

---------------------------         -----------------------------               ----------------------------

Any Side Effects?             Any Side Effects?                     Any Side Effects?

---------------------------         ---------------------------                 ----------------------------

Your Name & Phone Number 

------------------------------------------------------------

Doctors Name & phone Number                                        Did it work?

-------------------------------------------------------------               -----------------------------

What Pharmacy filled Rx?

-----------------------------------------

Take this list with you when you go to the doctor, so he can go over all Perscription and Non-Perscription medications you take. Be sure to list even the "Over the Counter" drugs and/or herbs you take!