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Medication Reconciliation Form
The past 2 weeks
(including inhalers, ear/eye drops, creams, gels, suppositories and any other “over-the-counter” (OTC) medications etc.)
Name
Dose
Route
Frequency
Date/Time of last dose
Natural health products (including vitamins, herbal products, probiotics, homeopathic treatment, etc.)
Name
Dose
Route
Frequency
Date/Time of last dose
Vaccination
2 months
DCaTP-Hib Pneumo. conj.
12 months RRO MenC Varicelle Pneumo. conj.
4th year Hepatitis B VPH
4 months
DCaTP-Hib...
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