Maryland Brain, Spine + Pain Medication & Allergy History 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Patient Name' field at the top of the form.
3. In the section labeled 'I am taking the following Medications', list all current medications you are taking. Use multiple lines if necessary for clarity.
4. Next, provide the original date when you started these medications in the 'Original Date' field.
5. Fill in the dosage for each medication in the corresponding 'Dosage' fields provided.
6. In the 'Medicines I am Allergic To' section, list any known allergies to medications.
7. Indicate how frequently you take each medication in the 'Frequency' section.
8. Describe any allergic reactions you have experienced in the 'Allergic Reaction' fields.
9. Finally, review your entries and sign at the bottom of the form, including today's date.

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