CONCOMITANT MEDICATION LOG TEMPLATE

STUDY NO.	STUDY TITLE	PRINCIPAL RESEARCHER	SUBJECT ID	SUBJECT INITIALS
Ask Participant: Are you currently taking any medications (i.e., prescriptions, vitamins, supplements, OTC drugs)?
NO.	MEDICATION / THERAPY	INDICATION	DOSE	DOSE UNITS	FREQ	FORM	ROUTE OF ADMINISTRATION	START DATE dd/mm/yy	END DATE dd/mm/yy	BASELINE MED Yes / No	CONTINUING AFTER STUDY Yes / No
Signature of Principal Researcher	Date	*To be signed at the end of the study

CODING
CODE	DOSE UNITS	FREQ	FORM	ROUTE OF ADMINISTRATION
01	mg (milligram)	QD (once/day)	Tablet	Oral
02	µg (microgram)	BID (twice/day)	Capsule	Topical
03	L (liter)	TID (three/day)	Ointment	Subcutaneous
04	mL (milliliter)	QID (four/day)	Suppository	Intradermal
05	IU (International Unit)	QOD (every other day)	Aerosol	Transdermal
06	g (gram)	QM (every month)	Spray	Intraocular
07	QOM (every other month)	Suspension	Intramuscular
08	QH (every hour)	Patch	Inhalation
09	AC (before meals)	Gas	Intravenous
10	PC (after meals)	Gel	Intraperitoneal
11	PRN (as needed)	Cream	Nasal
12	Powder	Vaginal
13	Implant	Rectal
14	Chewable
15	Liquid
99	Other, define	Other, define	Other, define	Other, define

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