Instructions for Your Nephrology Appointment

Why Your Complete Medication List Protects Your Kidneys

Your kidneys filter and process many of the medications you take daily. To ensure Dr. Masood and Dr. Siddiqui can establish safe dosages, prevent harmful interactions, and protect your remaining kidney function, our team reconciles every prescription, over-the-counter medicine, vitamin, and herbal supplement at every visit.

✓ Record exact medication names, milligram dosages, and daily frequencies.

✓ Print and fill this form by hand, or simply bring all current pill bottles in a bag.

Kidney Specialist Inc. • Sheikh M. Masood, MD • Mohammed M. Siddiqui, MD

MEDICATION LIST

Patient's Name:

D.O.B:

Date:

DID PATIENT BRING MEDICATION?

YES NO

DID PATIENT BRING A LIST?

YES NO

Allergies / Adverse Drug Reactions: [ ] NKDA (No Known Drug Allergies) Known:

#	MEDICATION NAME	DOSE	FREQUENCY	INITIALS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Please hand this completed form to the clinical triage nurse or front desk staff.