eternity Cindy and Ian Rawlinson Acupuncturists
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Name _____________________________ Date________________________

Medications

Please list below all the allopathic medications and supplements you are taking, as well as the name of the doctor who prescribed them.

Medication________________________________ Dose______________________

Prescribed by______________________________Taken since_________________

Prescribed for________________________________________________________

Side effects__________________________________________________________

Medication________________________________ Dose______________________

Prescribed by______________________________Taken since_________________

Prescribed for________________________________________________________

Side effects__________________________________________________________

Medication________________________________ Dose______________________

Prescribed by______________________________Taken since_________________

Prescribed for________________________________________________________

Side effects__________________________________________________________

Medication________________________________ Dose______________________

Prescribed by______________________________Taken since_________________

Prescribed for________________________________________________________

Side effects__________________________________________________________

Medication________________________________ Dose______________________

Prescribed by______________________________Taken since_________________

Prescribed for________________________________________________________

Side effects__________________________________________________________