Medication List 
 
 
 
 

Medications List

As you are admitted to Twin Cities Community Hospital, our staff will make a record of the medications you take.  This information is important to our staff and physicians who coordinate your care at the Hospital.  Please print this page and provide the information as you are pre-admitted or admitted to the Hospital.

Your Name:

Your Birthdate:

Medication Name and Strength

What is the Dose?

How do you take the medication (routine)?

Reason for taking the medication?

When was the last time you took the medication before coming to Twin Cities (date & time)?

Who is the prescribing Physician for each medication?

1. ___________________________

2. ___________________________

3. ___________________________