BOULEVARD DENTAL ASSOCIATES

Patient List of Medications

Please list all medications taken within the last 10 years below: 

Name of Medication                          Purpose                              Dosage                             Frequency

1. _______________________     _________________        _______________            _________

2. _______________________     _________________        _______________            _________

3. _______________________     _________________        _______________            _________

4. _______________________     _________________        _______________            _________

5. _______________________     _________________        _______________            _________

6. _______________________     _________________        _______________            _________

7. _______________________     _________________        _______________            _________

8. _______________________     _________________        _______________            _________

9. _______________________     _________________        _______________            _________

10. _______________________     _________________        _______________          _________

Patient  Signature: ___________________________________         Date: __________________