**Medication Reconciliation Form**
*Patient's Initial: ABCDE*
*Age: 68*
*Weight: [Data not provided]*
*Height: [Data not provided]*
*Allergies: [Data not provided]*
*Diagnosis: COPD, Hypertension, Atrial Fibrillation*
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### MEDICATIONS TAKEN:
| Name of the Drug (Generic name and Brand name, if applicable) & Dose | Route | Frequency | Specify if (RESUMED, DISCONTINUED OR MODIFIED) (circle one) | SPECIFY MODIFICATION(S)


