Hydrocephalus/NPH

Sinai Hospital, Department of Neurology / 5051 Greenspring Avenue / Baltimore, MD 21209 / 410.601.9515 phone / 410.601.1901 fax

SINAI NEUROLOGY FACULTY PRACTICE Michel Mirowski Medical Office Building

5051 Greenspring Ave., Baltimore MD 21209 Phone: 410-601-9515; Fax: 410-601-8905

Welcome! This packet is for

Thank you for choosing the Berman Brain & Spine Institute and LifeBridge Health for your healthcare!

You have an appointment with Dr. Robin Wilson am on , , 20 at pm day of the week month and day

am You are expected to arrive at your registration time pm

The clinic is on the 2nd floor of 5051 Greenspring Avenue.

You will receive an automated reminder call 48 hours prior to your appointment. Someone from our office will call you the day before your appointment to remind you.

Things You Must Know or Do

1. Please bring discs that contain your brain MRIs or CT scans.

2. Read the pages of this packet for important instructions.

3. Complete and sign the forms on pages 5–15 of this packet before your visit and bring them with you when you come (do not mail them).

4. If your insurance company requires you to obtain a referral, it is your responsibility to do so.

5. If you do not arrive in sufficient time to allow for registration or if you do not bring a required referral, your appointment may be rescheduled.

6. Our building does NOT have an ATM machine. Please bring cash, check, or credit card (Visa, Master Card, or Discover—NOT American Express) for your co-pay and cash or credit card for parking (with our validation, the parking fee is only $3).

7. To print out more copies of this packet, go to www.lifebridgehealth.org/NeurologyAppointments.

Things You Must Bring

1. Insurance card 2. Co-pay, if necessary & money for parking 3. Photo ID 4. Referral, if necessary, and/or authorization from requesting physician. 5. Pages 5–15 of this packet completed & signed. 6. List of current medications (page 15 of this packet) or bring your medication bottles. 7. Discs with your brain MRIs or CT scans.

If you have any questions, please contact us at 410-601-9515

We look forward to caring for you.

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Directions to the Michel Mirowski Medical Office Building 5051 Greenspring Avenue Baltimore, MD 21209 410-601-9515

From the Northwest — From Carroll County, Owings Mills or Reisterstown, take I-795 to I-695 East (Baltimore Beltway, Towson direction). Take Exit 23 onto I-83 South (Jones Falls Expressway). Proceed for approximately 3 miles and take Exit 10B, Northern Parkway. Look below for directions from Northern Pkwy.

From the North — From Pennsylvania and northern Baltimore suburbs, take I-83 South. At junction with I-695 (Baltimore Beltway), enter I-695 heading West (Pikesville direction). Re-enter I-83 South at Exit 23. Proceed for approximately 3 miles and take Exit 10B, Northern Parkway. Look below for directions from Northern Parkway.

From the West — From Howard County and points west, head east on I-70 or on I-795 to I-695 East (Baltimore Beltway, Towson direction). Take Exit 23 onto I-83 South (Jones Falls Expressway). Proceed for approximately 3 miles and take Exit 10B, Northern Parkway. Look below for directions from Northern Parkway.

From the East and Northeast — From Towson, Harford County, and points farther north, take I-95 South to Exit 64, I-695 West (Baltimore Beltway, Towson direction). Take Exit 23 onto I-83 South (Jones Falls Expressway). Proceed for approximately 3 miles and take Exit 10B, Northern Parkway. Head west on Northern Parkway. Look below for directions from Northern Parkway.

From the South — From the DC, MD, VA area, take I-95 North into downtown Baltimore via the I-395 Exit. Turn RIGHT at W. Pratt Street. Turn LEFT at S. President Street, which becomes I-83N/Jones Falls Expressway. Take I-83 North approximately 6 miles to Exit 10B, Northern Parkway West. Follow directions from Northern Pkwy.

DIRECTIONS FROM THE HOFFBERGER BUILDING TO THE MIROWSKI BUILDING — From the Belvedere Garage turn right onto West Belvedere Avenue, turn right onto Northern Parkway. Turn right onto Greenspring Avenue. Follow directions below after turn onto Greenspring Avenue.

DIRECTIONS FROM NORTHERN PARKWAY TO MIROWSKI BUILDING — Proceed 0.6 miles up Northern Parkway and turn left at the stoplight onto Greenspring Avenue. Shortly after you pass under a footbridge across Greenspring Avenue, make the very first left into the driveway that leads up the hill to the parking lot. The driveway entrance is directly across from the Emergency Room (ER7) entrance and is marked by a blue sign pointing to the Mirowski Office Building and the Brain & Spine Institute.

The clinic in the Mirowski Building is on the 2nd floor.

Mirowski Office Building

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New Patient Packet—Important Information

Important Information

You will be seen in the Michel Mirowski Medical Office Building.

The clinic is on the 2nd floor of 5051 Greenspring Avenue.

Patient parking is located in front of the main entrance.

Please help us to be respectful to all of our patients and to our physicians. On the first page of this packet,

you were given an appointment time and a registration time.

If you do not arrive at the requested time, we may reschedule your appointment.

Please bring your insurance card and photo ID with you to every visit.

If your insurance requires a referral, please ensure that the referral is valid and that we have a copy of it prior to your visit. IT IS YOUR RESPONSIBILITY TO OBTAIN THE REFERRAL AND TO FOLLOW THROUGH TO ENSURE THAT WE HAVE IT. If you do not have your referral at the time of your scheduled visit, we may need to reschedule your appointment. Please inform us before your appointment of any changes in your insurance coverage.

PAYMENTS FOR CO-PAY AND PARKING Our building does NOT have an ATM machine. Please bring cash, check, or credit card (Visa, Master Card, or Discover—NOT American Express) for your co-pay and cash or credit card for parking (with our validation, the parking fee is only $3).

SCHEDULING, CANCELLATIONS, and NO-SHOWS After your initial visit, we will give you a follow-up appointment card. If you need to reschedule that appointment, please book your follow-up appointments as soon as possible because we are often full 6–12 weeks in advance. We will call you 2–3 days prior to your appointment to remind you. Please let us know (on page 9 of this packet) the best way to reach you (home, work, cell, and pager).

If for any reason you cannot make your appointment, please call 410-601-9515 to cancel at least 72 hours prior to your appointment.

If you do not arrive for your scheduled appointment and you have not canceled at least 24 hours in advance, you will be charged a $25 no-show fee.

NECESSARY MEDICAL INFORMATION FOR YOUR VISIT Please have available for your appointment the name, office address, and phone number of your referring physician and/or primary care provider so that we can communicate with him or her. Please bring a written list (on page 13 of this packet) of all medications that you currently take, including dose and frequency, or bring the medication bottles—this is important for new and follow-up patients.

If you have had any relevant testing (MRIs EEG, bloodwork, consultations/reports from other providers), please ensure that you bring the reports, actual images (either on film or CD), or both with you.

Do not assume that your primary care physician will send this information.

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New Patient Packet—Important Information

MESSAGES/PHONE CALLS We attempt to return all phone calls within 24 hours. Sometimes, your call will be returned by another physician or by a physician assistant.

PRESCRIPTION REFILLS For refills, your pharmacy must fax a refill authorization request to us at 410-601-8905. If we have no questions, we will refill your prescription. All refill requests will be completed within 2 business days of receipt, and you should follow-up with your pharmacy to check on the refill.

Please do not wait until the last minute to contact your pharmacy to request a refill.

If your pharmacy advises you of problems with the refill, call 410-601-9515, press #3, and leave a complete message. We will resolve any issues within 2 business days.

IF YOU EXPERIENCE PROBLEMS WITH YOUR MEDICATION AND NEED EMERGENCY CARE, CALL 911.

If you experience problems with your medication but do not need emergency care, call 410-601-9515, press #3, and leave a complete message. DO NOT call this phone line for automatic refill requests.

NOTE: If you have not been seen by one of our healthcare providers within the last year, we will not write a prescription for you until you have been seen in our clinic.

BILLING QUESTIONS Before your visit, we check to determine if your insurance is active and to obtain any authorizations that are required. However, it is your responsibility to obtain any referral that may be required by your insurance company and to determine your financial responsibility for your visit, including any amounts that will be charged against your deductible or co-insurance. If you require billing codes to determine your out-of-pocket expenses, we will be happy to provide them. We must receive the request for this information a minimum of 5 business days prior to your appointment.

Following your visit, you may receive two bills, one for physician services and one for hospital services.

For billing questions about your doctor’s bills, please call 410-469-4369. For questions about bills from Sinai Hospital,

call 410-601-1094 (800-788-6995 out of Baltimore area). For questions about bills from Northwest Hospital,

call 410-521-5959 (877-617-1803 out of Baltimore area).

We know that the payment and the insurance process related to your visit may seem confusing. Please do not hesitate to ask any staff member for clarification. We are here to ensure that your visit is productive, positive, and comforting.

Our staff is committed to providing quality care and customer service to all of our patients. Your safety and privacy are important to us, and we will do our utmost to safeguard them. If during your visit you have any questions or concerns, please do not hesitate to let us know. If at any time you are not satisfied with the handling or resolution of your concern, you may contact Guest Relations at 410-601-8778.

Thank you for your attention to our policies. We look forward to seeing you and will do our best to provide you with excellent care.

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The information furnished above will be used ONLY for billing and accounting purposes.

Neurology Registration (rev 12/17)

DEPARTMENT OF NEUROLOGY

New Patient Registration Sheet

Please complete these documents and bring them with you on the day of your appointment. Name: Date: Social security #: DOB: Sex: Address: City, state, zip Home phone: Work phone: Cellphone: email address: Marital status: Languages: Religion: ADVANCE DIRECTIVES ~ Do you have a living will or advance directive? Yes No Have you named a person to make medical decisions for you if you are unable to make them for yourself? Yes No If so, who is that person? INSURANCE HOLDER EMPLOYMENT INFORMATION Name of insured if other than patient: SSN: DOB Relationship: Employer: Occupation: Address: Phone: City, state, zip: Primary (main) insurance company: Effective date: Retirement date: Insurance ID number: Secondary (supplemental) insurance company: Effective date: Retirement date: Insurance ID number:

~ PLEASE CONTINUE TO THE OTHER SIDE OF THIS SHEET ~

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Neurology New Patient Registration Sheet

The information furnished above will be used ONLY for billing and accounting purposes.

Neurology Registration (rev 12/17)

Please complete these documents and bring them with you on the day of your appointment.

Patient name DOB EMERGENCY CONTACT Name: Relationship: Work number: Home number: REFERRING PHYSICIAN Name: Phone: FAX: Address: City, state, zip: PRIMARY CARE PHYSICIAN Name: Phone: FAX: Address: City, state, zip: Please list other physicians who see the patient regularly.

Name Specialty Phone

PHARMACY Name: Phone: FAX:

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Authorization & Assignment

Authorization and Assignment of Insurance Benefits

Patient name DOB The undersigned patient, or authorized individual acting on behalf of the patient, understands and agrees to the following:

1. I authorize payment of medical benefits to the physician(s) rendering service(s).

2. I agree and acknowledge that my signature on this document authorizes my physician(s) to submit claims for benefits, services rendered, or services to be rendered without obtaining my signature on every claim submitted for me and/or my dependent(s). I will be bound by this signature as though the undersigned had personally signed the particular claim.

3. I will pay to the physician(s) any balance due for services rendered. I understand that if payment is not made on my behalf (by my insurer, legal representative, or workers compensation insurance), I will be responsible for any outstanding balance.

4. I understand that the Sinai Department of Neurology checked with my insurance company prior to this visit to determine whether my insurance is active and to obtain any required authorizations.

5. If I have received neurodiagnostic testing, I understand that following my visit, I will receive two bills—one for the doctor's services and one for the hospital's services.

6. I understand that it is my responsibility to obtain any referrals required by my insurance company and to determine my financial responsibility for all charges for this visit, including those from the doctor and from the hospital and any amounts that will be charged against my deductible or co-insurance.

The reason for this visit is not the result of a motor vehicle accident and is not covered by my automobile insurance.

The reason for this visit is the result of a motor vehicle accident, and the claim for services provided should be submitted to my insurance carrier:

insurance company claim number adjuster's phone number The reason for this visit is not the result of a Workers Compensation claim and, therefore,

payment for this visit is not eligible for payment by Workers Compensation insurance.

The reason for this visit is the result of a Workers Compensation claim, and the claim for services provided should be submitted to my Workers Compensation carrier:

Workers Compensation carrier claim number adjuster's phone number

I UNDERSTAND THAT IF I HAVE NOT PROVIDED CORRECT AND TRUTHFUL INFORMATION REGARDING THE

REASON FOR THIS VISIT AND INSURANCE COVERAGE, I WILL BE RESPONSIBLE FOR ANY UNPAID CLAIMS. signature of patient, parent/guardian, guarantor date

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Patient Authorization

Patient Authorization

Patient name DOB The providers in the Department of Neurology are dedicated to preserving your privacy and personal health information. Our employees are trained in the proper handling of your medical and financial records. We are requesting this patient authorization in order to continue to provide the finest medical care possible. Thank you for your assistance.

I authorize the Department of Neurology to:

1. Call my home and/or work to remind me of upcoming appointments; in the event I am not there, leave a message on an answering machine.

2. Send reminder notices for upcoming appointments or when it is time to schedule an appointment.

3. Send me notices, clinical notes, and lab results via: text message email

4. I would like to receive an email invitation that provides instructions on how to register for the Sinai Hospital Patient Portal.

yes no please print email address

5. Call my home or work and leave a message to contact the office. My preferred method of contact for appointment reminders is

home phone cell phone text message on cell phone email

home phone number cell phone number

6. Make and/or receive calls from pharmacies on my behalf, including prescriptions by FAX.

7. Update my personal demographic information either on the phone or in the office at the time of my appointment.

8. I give permission to discuss my personal health with the designated person(s) below: (We will conduct all correspondence with the primary contact unless it is an emergency and the primary contact cannot be reached.) name of primary contact relationship name of secondary contact relationship I have read and agree to the above policies. patient name (print) date signature of patient healthcare agent surrogate date

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This authorization will expire within 1 year unless otherwise indicated. The consent to disclose information may be revoked by me at any time in writing except to the extent that action has been taken in reliance thereon, as set forth in the LifeBridge Health Notice of Privacy Practices. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment. Subsequent re-disclosure or recopying of this information is not authorized without specific consent of the patient or authorized representative as provided in the Annotated Code of the State of Maryland, Article 4-302 (d) *Photo Id may be requested at the time of release.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Patient's Date of BirthPatient's Name

Patient's Street Address Social Security Number

Phone NumberCity, State, Zip Code

I, the undersigned, hereby authorizeto release copies of medical records to: to obtain copies of medical records from:

Verbal release only of medical information to:

Name of Person or Agency Phone Number

Address Fax NumberCity, State, Zip Code

The purpose or need for such disclosure is

Dates of Service:

is authorized to release the following: (Please check information

Abstract (Summary, Op Report, Paths, Consults, H&P, lab work)Emergency Room RecordOutpatient SurgeryDischarge SummaryAdmission History and PhysicalConsultation ReportHIV / AIDS ReportDoctor's Office NotesOperative Report / Pathology Report

Alcohol / Detox / Drug Abuse X-ray, EKG, EEG, Labs, CardiopulmonaryPhysical Therapy / OT / Speech Nuclear MedicineClinic Mental Health / PsychiatryOther

Signature Date Relationship to Patient

Witness Date

ate

MR# Date Completed Completed By # pages

to be released) The medical records to be released may contain medical information pertaining to mental health services, drug and/or alcohol diagnosis and treatment, HIV / AIDS testing, HIV / AIDS results or HIV / AIDS information.

MR7350-501-L (12/05)

MR7350-501-L

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Patient name:

MEDICAL HISTORY—1. Have you ever had any of the following medical problems? Please answer all items.

Yes No Describe Date of Onset Heart disease □Heart attack Chest pain or angina Palpitation/irregular heart beat Pacemaker High blood pressure High cholesterol or lipids Lung disease □Shortness of breath Asthma/wheezing Emphysema/COPD Bronchitis Kidney disease □Prostate enlargement/cancer Bladder problem/surgery Hepatitis (jaundice) □Hiatal hernia, reflux or ulcers Unexplained weight loss/gain □Cancer, lymphoma, leukemia Anemia □Sickle cell disease/trait Vitamin deficiency Abnormal blood clotting/coagulation Diabetes □Thyroid disease Glaucoma □Cataracts Macular Degeneration Inner ear problem/vertigo □Hearing impairment/Deafness Stroke or TIA □Paralysis Fainting spells Seizures or epilepsy Sleep apnea or disorder Depression or mood disorder □Treatment by a psychiatrist Arthritis □Back or neck surgery Hip, knee or foot surgery Lupus/Autoimmune disease □HIV/AIDS, immunosuppression Skin disorders □Syphilis Drug or alcohol use

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Patient name: 2. Please list all hospitalizations or operations: Year

3. Have you ever had a blood transfusion? .................................. yes no

4. Do you now smoke? ................................................................. yes no

If yes, indicate: cigars cigarettes pipe amount smoked daily:

5. Have you smoked in the past? yes no year quit:

6. What is your weight? pounds When did you last weigh yourself?

7. What is your height? (If you’ve become shorter, list your tallest height) ____feet ____inches

8. FOR WOMEN ONLY:

a. Date of your last menstrual period:

b. Is it possible that you are pregnant at this time? unsure yes no

c. How many vaginal (normal) deliveries have you had?

d. How many cesarean (C-section) deliveries have you had?

9. What medical illnesses have you had that haven’t been described earlier on this form?

10. What surgical procedures have you had that haven’t been described earlier on this form?

11. List any medical illnesses associated with your family:

Grandparents

Parents

Brothers/sisters/children

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Patient name: ALLERGIES

12. Are you allergic to any medicines? ....................................................... yes no Medication Description of allergic reaction

13. Are you allergic to adhesive tape? ...................................................... yes no

14. Are you allergic to iodine or seafood? ................................................ yes no

LIVING WILL/ADVANCE DIRECTIVE

15. Do you have a living will or advance directive? ................................... yes no

16. Have you named a person to make medical decisions for you if you are unable to make those decisions for yourself? ....................... yes no

17. If so, who is that person?

CULTURAL/RELIGIOUS CONSIDERATIONS

18. Should we know about any cultural/religious considerations as we provide your care? yes no

If so, please explain:

If you have any additional comments or medical information you think might be helpful to us, please feel free to write in the blank space provided or attach extra pages to this form.

________________________________________________ ___________________ patient signature date ________________________________________________ ________________ signature of person (if other than patient) who filled out this form relation

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Patient’s name Today's date

Instructions: Please complete this form no more than 7 days before your appointment. Please answer all questions; they are important for understanding your diagnosis. Do not leave any unanswered. Take your time and read each question carefully before answering it. For multiple choice questions, check the box next to the one best answer, unless the question specifically directs you to do otherwise. For questions that require you to write an answer, please write legibly.

1. How long have you had the health condition for which you are seeking treatment today? Specify the length of time in years and months.

Number of years _____ Number

of months _____

WALKING AND BALANCE

2. Do you have a problem getting in or out of a seat, walking, or maintaining your balance? Yes No

3. How long has it been since you first had a problem getting in or out of a seat, walking, or maintaining your balance? Specify time in years and months.

Number of years _____ Number

of months _____

4. In the past month, how often did you have a problem getting in or out of a seat (e.g., chair, toilet, sofa)?

Never

Sometimes

Always

5. In the past month, how often did you misjudge the distance to a seat or fall into it when trying to sit down?

Never

Sometimes

Always

6. In the past month, how often did you have a problem getting in or out of a car? Never

Sometimes

Always

7. In the past month, how often did you have a problem starting to walk (feeling like your feet were stuck to the floor)?

Never

Sometimes

Always

8. In the past month, how often did your feet shuffle or scuff as you walked? Never

Sometimes

Always

9. In the past month, how often did you have a problem coming to a stop as you walked?Never

Sometimes

Always

10. In the past month, how often did you have a problem turning or changing direction as you walked?

Never

Sometimes

Always

11. In the past month, how often did you have a problem walking on uneven surfaces, grass, or stepping over a curb?

Never

Sometimes

Always

12. In the past month, how often did you hold someone’s hand, or touch walls, furniture, or countertops as you walked?

Never

Sometimes

Always

13. In the past month, which of the following did you use to help you get around? (Mark all that apply)

None

Cane

Walker

Walker with wheels

Wheel chair

Electric cart or scooter

14. In the past month, how often did you fall down to the floor while getting in or out of a seat, standing, or walking?

Never

Sometimes

Always

15. In the past month, how often did you nearly fall down, but kept yourself from landing on the floor?

Never

Sometimes

Always

16. In the past month, how often did you avoid stairs? Never

Sometimes

Always

BLADDER AND BOWEL

17. Do you have a problem controlling your bladder? Yes No

18. How long has it been since you first had a problem controlling your bladder? Specify the time years and months.

Number of years _____ Number

of months _____

19. Compared to the time before your bladder problem began, do you urinate more frequently than you used to? Yes No

20. In the past month, how often did you lose control of your bladder (incontinence)? Never

Sometimes

Always

21. In the past month, how often did you wear a pad or undergarment (like Depends) for incontinence?

Never

Sometimes

Always

22. In the past month, how often did you have trouble starting to urinate, or continuing to urinate once you started?

Never

Sometimes

Always

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Patient’s name Today's date

THINKING, MEMORY, AND DAILY ACTIVITIES 23. Do you have trouble with your thinking and memory? Yes No 24. How long has it been since you first had a problem with your thinking

and memory? Specify time in years and months. Number of years _____ Number

of months ____

25. In the past month, how often did you have trouble with your memory (e.g., forgetfulness, repeating questions, trouble with learning or short-term memory)?

Never

Sometimes

Always

26. In the past month, how often did you have trouble with orientation (e.g., getting lost, confused, disoriented, losing track of time or appointments, not recognizing familiar places or persons)?

Never

Sometimes

Always

27. In the past month, how often did you have trouble with judgment or solving everyday problems at home (e.g., leaving water running or stove burners on; managing your medications or money; understanding explanations)?

Never

Sometimes

Always

28. In the past month, how often did you have trouble caring for yourself (e.g., dressing, using the toilet, bathing, eating)?

Never

Sometimes

Always

29. Are you currently working for money? Yes No 30. What kind of work do you, or did you do for

money? Please be specific. ______________________________________________________

31. Has your condition caused you to stop working for money (job loss, disability, early retirement)? Yes No

32. During the past month, how often have you felt sad, discouraged, or hopeless? Never

Sometimes

Always

TESTING AND TREATMENT 33. Have you had physical or occupational therapy as a treatment for your health condition? Yes No

34. Have you been treated either with medications or surgery for Parkinson disease? Yes No

35. Have you been treated with medications for dementia or Alzheimer disease? Yes No

36. Have you been treated either with medications or surgery for your bladder problem? Yes No

37. Have you had spinal fluid removed (spinal tap or lumbar puncture) as a test for your health condition? Yes No HYDROCEPHALUS RISK FACTORS 38. Have you ever had a head injury, concussion, or been knocked out or unconscious? Yes No

39. Have you ever had meningitis (including spinal meningitis)? Yes No

40. Have you ever had encephalitis? Yes No 41. Have you ever had a ruptured brain aneurysm, blood vessel, arteriovenous malformation

(AVM), or brain hemorrhage? Yes No

42. Have you ever had a brain tumor? Yes No

43. Have you ever had radiation treatments or stereotactic radiosurgery to the brain, head, face, or neck? Yes No

44. Were you born with hydrocephalus or did you develop hydrocephalus before age 1 year? Yes No

PERSONAL INFORMATION 45. What is your gender? Male Female

46. What is your date of birth? Month Day Year How old were you on your last birthday?

48. Circle the highest level of formal education you have completed.Grade School 1 2 3 4 5 6 7 8

High School 9 10 11 12

College 1 2 3 4

Graduate School Some Completed Highest degree attained: HELP ANSWERING THIS QUESTIONNAIRE 49. Did someone else help you answer or fill out any part of this questionnaire for any reason? Yes No

50. To the person who helped: (Mark all that apply) I helped answer or fill out this questionnaire because the patient:

Had trouble writing Was too slow Didn’t know the answer(s) Is unaware of symptom(s)

Denies symptom(s) exist or thinks they are not as bad as I think they are Other

51. To the person who helped: How much of the questionnaire did you help the patient with?

None of it Almost none of it Some of it About half of it Most of it Almost all of it All of it

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Patient’s name Today's date

MEDICATIONS

What medications are you currently taking? What is the dose? How often do you take each medication? Please list all prescriptions, over-the-counter medications, vitamins, or supplements you are taking.

a. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

b. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

c. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

d. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

e. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

f. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

g. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

h. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

i. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

j. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

k. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

l. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

m. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

n. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

o. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

p. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

q. Name of medication:

Dose/Strength:

1 time a day

2 times a day

3 times a day

4 times a day

As needed

Other

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