Smgepqntaf04(1009).indd

Medication History
Please circle any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
Atropine, Ipratopium, Scopolamine, Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan
Acetylcholinesterase Reactivators
Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine,
Vecuronium, Hemicholine
Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum,
Megadon, Serax , Restoril, Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien, Sonata, Lunesta, Imovane
Cholinesterase Inhibitors (irreversible)
Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine,
Carbamate Insecticidses
Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)
Dopamine Receptor Agonists
Mirapex, Sifrol, Requip
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol,
Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify
GABA Antagonist Competitive binder
Flumazenil
Monoamine Oxidase Inhibitor (MAOI)
Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid
Noradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa)
Noradrenergic and Specifi
Remeron, Zispin, Avanza, Norset, Remergil, Axit
Selective Serotonin Reuptake Inhibitor
Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil,
Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine
Selective Serotonin Reuptake Enhancers
Stablon, Coaxil, Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine
Tricylic Antidepresseants (TCAs)
Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden,
Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil
*Please refer to prescribing physician for nutritional interactions with any medications you maybe taking.
All Rights Reserved. Copyright 2008, Datis Kharrazian

Source: http://wolinwellnesscenter.com/forms/medication_history.pdf