Patient Center
Medication Worksheet
Print this page and fill it in by hand, or use it as a guide. Bring it to your appointment. Nothing written here is sent to Rosecare through the website.
Privacy: this is a blank sheet. There are no fields to type into, nothing is stored in your browser, and nothing is sent to Rosecare. Fill it in on paper, or use it as a guide for the list you bring.
| Medication or supplement | Dose and how often | What it is for | Prescribed by | Started / notes (side effects, missed doses) |
|---|---|---|---|---|
Allergies or reactions to medications:
Pharmacy name and phone:
Rosecare Behavioral Health · Justina N. Anyanwu, DNP, PMHNP-BC
Tips
- Include over-the-counter medicines, vitamins, and supplements
- Note anything that was stopped recently and why
- List allergies or reactions to medications at the bottom
- If a pharmacy prints your medication list, that works too
Getting ready to see patients
Online scheduling and practice contact options are being finalized. In the meantime, learn what a first visit at Rosecare involves.