Drug Interaction Report Request Form
Name
Email
Sex
Female
Male
Age
1
2
3
4
5
6
7
8
9
1
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100+
Drug Name & Drug Strength (mg., mcg., etc.):
Times Taken Per Day:
1.
1.
1
2
3
4
5
6
7
8
9
10+
2.
2.
1
2
3
4
5
6
7
8
9
10+
3.
3.
1
2
3
4
5
6
7
8
9
10+
4.
4.
1
2
3
4
5
6
7
8
9
10+
5.
5.
1
2
3
4
5
6
7
8
9
10+
6.
6.
1
2
3
4
5
6
7
8
9
10+
7.
7.
1
2
3
4
5
6
7
8
9
10+
8.
8.
1
2
3
4
5
6
7
8
9
10+
9.
9.
1
2
3
4
5
6
7
8
9
10+
10.
10.
1
2
3
4
5
6
7
8
9
10+
List any other medications or over-the-counter medications not listed above.
Verification
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