Medication Reconciliation

Hospital Admission - Medication Reconciliation Form

Patient Name: Cheryl Guzman DOB: 04/22/1996 Room: 2-641-D	Allergies: Neomycin (rash & swollen lips/eyelids, 7 yrs ago)	Immunization History: Flu (last Sept), Tdap (6 yrs ago), COVID-19 (Moderna, series complete + 1 booster)
Community Rx Info: Good Neighbor Pharmacy (Birch St.) Rx Insurance: Cigna	Social History: never smokes or uses nicotine, drinks 1 glass wine/day, no rec drugs, 2-3 cups coffee/day

Complete Medication History Prior to Admission								Med Reconciliation
Medication Name	Strength	Route	Frequency	PRN?	Last Dose (date/time)	Adverse Effects	Adherence	Action	^*Reason for D,H,M
Fluoxetine (PMDD)	20 mg tab	by mouth	every morning	☐	yesterday at 9 am	none	never misses dose
Propranolol (migraine)	20 mg tab	by mouth	four times daily	☐	yesterday at 9 pm	dry mouth	misses 2-3 doses/week
Imitrex (migraine)	100 mg tab	by mouth	1 tab as needed for migraine	☐	2 weeks ago	dizziness	N/A
OTC - Align Probiotic	regular strength cap	by mouth	1 cap every morning for digestion	☐	yesterday at 9 am	none	never misses dose

Additional Notes:	Action Key: C = Continue ^*Must provide reason: D = Discontinue, H = Hold, M = Modify
Med history obtained by (sign and print):	Date: