Medication Prescribed by a Provider Rx (outside the VA)
Non-prescribed Medication Purchased Over-The-Counter OTC (like Tylenol, cough syrup, etc.)
Other Herbal/Supplemental Medication H/S (like Ginseng, St. Johns Wart, multivitamins, Boost, Ensure, etc.)
What is the name of the medication you are taking?
Each time you takeyour medication,how much do you take?
How often do you takeyour medication?
Why do you take your medication?
Who is the prescribing doctor?
Prescribing doctor's Phone Number
Which pharmacy filled the prescription?
Pharmacy's Phone Number
Please review the information youhave entered above for accuracy.