U B - M E D I C A L
C E N T E R
Pharmacy Department
Dr. Cecilio Putong Street, Tagbilaran City, Bohol, Philippines 6300
MEDICATION RECONCILIATION FORM
Patient’s Name: ___________________________________ Age: _____________
Physician/s: ________________________________ ________________________
Phone Number: _______________
Do you have any known drug allergy or sensitivity? ______Yes
_______No
Please list (with date) and define reaction:
___________________________________________________________________
___________________________________________________________________
Collect all medication history of all prescriptions, OTC products, herbals, and
vitamins/ supplements
Medication name
and strength
How do you
take it?
(Route and
timing)
How often
do you
take it?
Why do you
take this
medication?
Comments/
Notes
*drug-drug
interaction,
food-drug
interaction
(if any)