Use this form to help keep track of your medical history and current medicines. This can help you and your doctor determine the right treatment plan for you. Remember to keep the form updated with any changes. And bring it along to each doctor’s visit.

Current medical conditions (list all current, or ongoing, medical conditions):

Previous medical conditions (list all medical conditions, including major illnesses, you’ve suffered in the past):

Surgical history (list all surgeries or surgical procedures you’ve undergone):

Allergies (list all allergies to medications and other substances):

Current Medications (list all medications you are taking, including prescription and nonprescription [over-the-counter] medicines as well as vitamins, herbs, or other supplements):

Please visit PRADAXA.com for Medication Guide.

Want to learn more about PRADAXA?Ask your doctor about PRADAXA. And visit www.PRADAXA.com or call 1-877-51PRADAXA to learn if you are eligible to save on your prescription with the PRADAXA Savings Card. Eligibility, restrictions and terms & conditions apply.

Boehringer Ingelheim Pharmaceuticals, Inc. either owns or uses the trademarks Pradaxa® and PRADAXA with associated design ® under license. Copyright © 2016 Boehringer Ingelheim Pharmaceuticals, Inc. All rights reserved. [10/16] PC-PX-0253-CONS

MEDICAL HISTORY & MEDICATIONS LIST