Screening · About 4 minutes

Medication review and reconciliation

An accurate medication list is one of the most important safety steps in your care.

About you

Full name*

Date of birth*

Telephone

Please give at least a telephone number or an email address so the office can reach you.

Current medications

Prescription medications — one per line with dose and how often you take it

For example: Lisinopril 10 mg, once daily

Over-the-counter medications you take regularly

Vitamins, supplements, and herbal products

Safety

Medication allergies and the reaction each caused

Do you regularly miss doses or run out of medication?*

YesNo

Are you having side effects you would like to discuss?*

YesNo

If yes, please describe (optional)

Preferred pharmacy name and location

Other clinicians who prescribe for you

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

Medication review and reconciliation

Other screenings