Dietary Supplement Diary

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Dietary Supplement Diary
Name of Supplement
How Often
Amount
500 mg , 1 tablet, etc.
Reasons for Taking:
Name
Age
Date
Are you currently taking or have you recently taken any over-the-counter medications (e.g., aspirin, cold medicine, stool softener, pain reliever, etc.)?
If Yes, list medications:
What prescription medication(s) are you currently taking, if any?