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Gagandeep Singh, M.D., LLC – Medication History Form If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were. Your best approximation of dates and dosage is helpful, even if you are unsure. ___________________________________________________________ __________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Gagandeep Singh, M.D., LLC – Medication History Form ___________________________________________________________ ___________________________________________________________ Antipsychotics (used for a variety of reasons, including mood stabilization and impulsivity/aggression): ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Gagandeep Singh, M.D., LLC – Medication History Form ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Gagandeep Singh, M.D., LLC – Medication History Form ___________________________________________________________ Dexosyn (methamphetamine) ___________________________________________________________ Ritalin/SR/LA (methylphenidate) __________________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Source: http://www.gsinghmd.com/web_documents/medication_history.pdf

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