BRIDGE RECOVERY HOUSE

STUDENT APPLICATION

Date

Name Age
Last First Middle

Gender at Birth Height Weight Eye Color

Social Security # Birth Date

Permanent Address:
Street Number, Name and Apartment/Lot Number

City State Zip

Phone # ( ) - Cell Phone # ( )

Education: Housing Situation: Marital Status: Citizenship: Race:

❑ Bachelor's Degree ❑ Live with Spouse ❑ Single ❑ United States ❑ White

❑ Associate's Degree ❑ Live with Parents ❑ Married ❑ Other ❑ Black
❑ 1+ Yrs of Trade School ❑ Live with Relatives ❑ Divorced ❑ Hispanic
❑ H.S. Diploma ❑ Live with Friends ❑ Engaged ❑ American Indian
❑ GED ❑ Incarcerated ❑ Separated English Skills: ❑ Asian
❑ Dropped out of H.S. ❑ Homeless ❑ Widowed ❑ I Read English ❑ Middle Eastern
❑ Still Attending H.S. ❑ Live Alone ❑ Other ❑ I Speak English ❑ Other
❑ Current Grade ❑ Other ❑ I Write English

Religion: Denominational Preference:

❑ Protestant ❑ Assemblies of God ❑ Evangelical Free ❑ Missionary Alliance

❑ Catholic ❑ Baptist ❑ Lutheran ❑ Non-Denominational
❑ Other ❑ Church of God ❑ Inter-Denominational ❑ Presbyterian
❑ Evangelical Covenant ❑ Methodist ❑ Other

I Need Help With the Following: (Check all that apply):

❑ Alcohol Addition ❑ Anxiety ❑ Aggression ■■■

Self-Mutilation
Ell Drug Addiction ❑ Anger ❑ Abandonment ❑ Terminal Illness
❑ Tobacco Addition ❑ Depression ❑ Eating Disorders ❑ Suicidal Thoughts
❑ Gambling ❑ Grief ❑ Forgiveness ❑ Death of a Loved One
❑ Pornography ❑ Fear ❑ Emotional Stress ❑ Family Relationships
111 Homosexuality ❑ Guilt ❑ Self Esteem ❑ Parenting

Referred by:
Phone #:
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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Medical Information: (Check all that apply to your current or past conditions)

❑ ADD Diabetes ❑ High Blood Pressure ❑ Rape

❑ ADHD ❑ Drug Abuse ❑ HIV Virus ❑ Respiratory Problems
❑ Alcohol Abuse ❑ Eating Disorder ❑ Homicidal Tendency Schizophrenia
❑ Anorexia ❑ Flashbacks ❑ Homicidal Thoughts Seizures
❑ Asthma ❑ Hallucinations ❑ Insomnia O Sexual Abuse
❑ Back Problems 1 Head Trauma ❑ Mental Illness ❑ Suicide Attempts
❑ Back Problems ❑ Hearing Voices • Multiple Personalities • Suicide Contemplate
❑ Bulimia ❑ Heart Condition ❑ Nervous Condition ❑ Suicide Thoughts
❑ Depression ❑ Hepatitis ❑ Paranoia Tuberculosis
Physical Abuse ❑ Venereal Disease

Substance Abuse: (Check all that you have used)

Alcohol
.■■■••
❑ Crack Huffing/Sniffing
■■•■
E Mushrooms
❑ Amphetamines ❑ Ecstasy ❑ LSD ❑ PCP
❑ Barbiturates ❑ GHB/MDMA ❑ Marijuana _ Over the Counter Drugs
❑ Cocaine Heroin ❑ Meth _ Prescription Drugs
❑ Other

What was the date you last used any of the above substances?

Drug of choice: Method of Use: ❑ Inject Snort ❑ Smoke ❑ Oral ❑ Other

Do you use tobacco? ❑ Yes ❑ No If yes, check all that apply: ❑ Cigarettes/Cigars ❑ Chew/Snuff

Treatment History:

Have you ever been in a residential treatment facility? ❑ Yes ❑ No How many?
Have you ever been treated for mental disorders? ❑ Yes No
Have you ever been treated for sleep disorders? Yes ❑ No
■■•

Has a Psychiatrist ever treated you? ❑ Yes ❑ No Last visit: /.

Has a Psychologist ever treated you? Yes ❑ No Last visit:

Medications:
List all current medications:

ALL MEDICATIONS MUST BE IN A LABELED PRESCRIPTION BOTTLE AT THE TIME OF ENTRANCE. IF YOUR
DOCTOR GIVES YOU SAMPLES, ASK YOUR PHARMACIST TO ASSIST YOU IN THIS MATTER.

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Medical Information Continued:

List any additional medications you have taken in the past 2 years:

Special Needs:
Do you have any type of disability? III Yes ❑ No Type:
Do you require a special diet? ❑ Yes ❑ No Type:
Do you have any medical restrictions? ❑ Yes ❑ No Type:
Do you have any allergies? ❑ Yes ❑ No Type:
Do you have any chronic conditions? ❑ Yes No Type:
❑

Do you have any other type of special needs? ❑ Yes ❑ No Type:

If you have any medical restrictions or disabilities, you must supply us with documentation from your
physician at the time of entrance into the program. We reserve the right to require this documentation
prior to acceptance.

Primary Emergency Contact: Secondary Emergency Contact:

Name: Name:
Relationship: Relationship:
Home Phone: Home Phone:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
Email: Email:

Insurance Provider: ID Number:

Name:
City: Sate: Zip:
Phone: FAX:

Primary Doctor Information:

Name:
Address: City: State: Zip:
Phone: FAX:
Dates of Treatment: / / to / /

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Name of Psychiatrist/Psychologist:

City: State:

Phone: FAX:

Dates of Treatment: / / to _J._J

Reason for Treatment:

Prior Treatment Facilities:

Name of Facility:

City: State:

Phone: FAX:

Dates of Treatment: / / to _/______/

Reason for Treatment:

Have you previously been in a Program? ❑ Yes ❑ No

If yes, Where? When?

Did you complete the program? ❑ Yes ❑ No If not, why?

Employment History: (Please list your last 5 places of employment)

Employer Duties Dates Employed Reason for Leaving

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 -

BRIDGE RECOVERY HOUSE

STUDENT APPLICATION

Legal information:

Current Legal Status:

Are you currently on probation? Yes No Type:

Are you currently on parole? Yes No Type:

Are you currently under investigation for anything? ❑ Yes No Type:

Do you currently have any outstanding warrants? .1■•

Yes ❑ No Type:

Are you currently involved in any type of lawsuit? Yes No Type:

Do you currently have any unpaid fines? Yes No Type:

Are you currently required to pay any restitution? L Yes No Type:

Are you currently ordered to do any community service? Yes No Type:

Are you currently required to pay child support? Yes No Type:

Are you currently behind in child support payments? Yes No Type:

Do you receive any Social Security Income? E Yes E No Type:

Do you receive any Disability? Yes ❑ No Type:

Do you receive any Unemployment Income? 1 Yes ❑ No Type:

Do you receive any retirement income benefits? Yes ❑ No Type:

Do you have any other source of income? E Yes ❑ No Type:

Past Legal Status:

Have you ever been arrested? ❑ Yes No Type:

Have you ever been in a juvenile detention center? Yes No Type:

Have you ever been sentenced to jail? ❑ Yes ••■•

No Type:

Have you ever been in prison? ❑ Yes No Type:

Have you ever been on probation? Yes ❑ No Type:

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Criminal Activity: Check all that you have been involved with)
Aiding & Abetting Driving without a License Probation Violation

Armed Robbery Drug Manufacturing Prostitution

Arson Drug Possession Rape

Assault DUI Restraining Order

Attempted Assault DWI Robbery

Attempted Burglary Embezzlement Sex with a Minor

Attempted Rape Escape from Custody Shoplifting

Attempted Robbery Felony Conviction Solicitation of Prostitution

Attempted Murder Fleeing or Eluding Police Stalking

Attempted Theft Fraud Terroristic Threats

Battery Harassment Theft

Burglary Incest Truancy

Car Jacking Kidnapping Underage Drinking

Child Abuse/Neglect Larceny Use of Firearm in a Crime

Child Molestation Leaving Scene of Accident Vandalism

Child Endangerment Manslaughter Vehicular Homicide

Child Pornography Murder Violation of No Contact Order

Concealed Weapon No Contact Order Violation of Order of Protection

Criminal Sexual Conduct Order of Protection Violation of Restraining Order

Disorderly Conduct Parole Violation Other:

Domestic Violence Possession of Stolen Property Other:

Parole/Probation Officer Information:

Name:

Address: City: State: Zip:

Phone: FAX: Email:

Do you have any court dates pending? Yes _ No If yes, give dates:

What are the charges?

Name of Defense Attorney:

Name of Prosecuting Attorney:

The Bridge Recovery House is not to be a part of your sentencing or a condition of your court order without prior
approval from the Intake Director. If you enter the program while on probation or parole, we must receive
approval from your probation/parole officer.

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Spiritual Information

Occult Activity: (Please check all that you have been involved with)

Animal Sacrifices Fortune Tellers Psychics Witchcraft

Astrology Ouija Boards Satan Worship Voodoo

Black Magic Palm Reading Seances Other:

Church Activity:

How often do you attend Church? ❑ Often ❑ Occasionally ❑

__ Seldom ❑ Never

How often do you read the Bible? ❑ Often ❑ Occasionally __

__ Seldom ❑ Never

How often do you pray? ❑ Often ❑ Occasionally ❑ Seldom ❑ Never

Have you ever accepted Jesus Christ as your personal Lord and Savior? ❑ Yes ❑ No Date:

Have you been baptized in water? ❑ Yes ❑ No Date:

Have you ever experienced being filled with the Holy Spirit? ❑ Yes ❑ No Date:

If you attend church, please provide as much of the following information as possible:

Name of Pastor:

Name of the Church:

Street Address:

City: State: Zip:

Phone #:

List any church activities you have participated in:

What do you believe about God?

What do you believe about life after death?

What is sin?

What purpose does the Bible and Prayer have in your life?

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

What are dome characteristics in your life that you would like to change?

In your own words, what do you think we can do to help you with your problems?

What words best describe how you feel about yourself?

What are your goals in life?

Describe your relationship with your family members:

What else would you like us to know about you?

 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Family Information: (Please provide complete information)

Spouse:

Name: Age:

Address:

City: State: Zip:

Phone: Work: Cell:

Date Married:

Is your spouse supportive of you being here? Yes No

Children:

Name: Gender: Age: Living with

Name: Gender: Age: Living with

Name: Gender: Age: Living with

Name: Gender: Age: Living with

Name: Gender: Age: Living with

Mother's Information:

Name:

Address:

City: State: Zip:

Phone: Work: Cell:

Father's Information:

Name:

Address:

City: State: Zip:

Phone: Work: Cell:

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Correspondence:
Please list the names and addresses of people you expect to correspond with while in the program. All mail is

read/censored by staff.

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Name: Relationship:

Address: City: State: Zip:

Please list additional family/friends on a separate page.

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Admission Agreement:

1. Bridge Recovery House is a residential Christian discipleship program. It consists of at least 12 months of
instruction.

2. Possession and/or use of drugs, alcohol and tobacco are prohibited while enrolled in our program. Students
may be given drug and/or alcohol tests at any time without prior notice. Students who test positive for drug
and/or alcohol use while in our program will face disciplinary action and possible expulsion from the program.

3. Students may not lend, buy or sell personal property to or from other students. Bridge Recovery House will not
be responsible for any personal property that becomes lost, stolen or damaged while on our premises.

4. Students, their rooms, and their personal property may be searched at any time without prior notice.

5. Students do hereby declare that any authorized staff member of Bridge Recovery House may open any incoming
or outgoing mail.

6. Students taking prescription medication must come in with at least a 30 day supply. A letter from your doctor
stating he/she will continue to supply you with prescriptions while in the program is required prior to entrance.
Documentation of the diagnosis for the medication must be brought at the time of admission.

7. I will not hold Bridge Recovery House responsible for any action taken, concerning myself, while I am
participating in the program. I will not file any legal charges or take any legal action, at any time, against Bridge
Recovery House or any authorized staff member. I release Bridge Recovery House from all financial and legal
responsibilities in case of accident, injury, illness or other misfortune.

8. If I leave voluntarily, or if I am dismissed prior to completion of the program, I will forfeit any and all money in
my student account.

9. Upon leaving Bridge Recovery House, I will take my personal belongings with me. I will not expect Bridge
Recovery House to be responsible for my possessions or to forward them to me.

10. If I fail to complete the program, I will not contact students in the program, their families, or any person I have
met as a result of my participation in the program. If I fail to complete the program, I agree to leave Lonoke
County, Arkansas and not return for at least a 12 month period.

11. Because of the high risk group, I understand that I may be housed with someone who is HIV positive. For this
reason, I will practice good daily hygiene.

12. I understand that Bridge Recovery House will correspond with my family members and friends listed on previous
pages in regards to fundraising opportunities.

Applicant Signature: Date:

Print Name:

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 BRIDGE RECOVERY HOUSE
STUDENT APPLICATION

Admission Requirements:

A. No applicant will be admitted without picture identification, social security card and a completed application.

B. Applicants requiring detoxification must do so prior to entry.

C. Applicants must be in good health, free of any infections at the time of entry.

D. Medical documentation of any disabilities or medical conditions requiring medication is required to accompany
medical application.

E. Upon entry, applicants will be tested for the HIV Virus, Tuberculosis, Venereal Disease and Hepatitis.

F. Applicants who are approved to enter the program as part of their probation, parole, or in lieu of sentencing
must supply us with documentation from said entities stating their approval and notification requirements. If
the program is a condition of probation or in lieu of sentencing, documentation must state you are required to
complete the entire program.

G. Upon entry, applicants will be required to pay an induction fee of $500.00

H. If applicant is receivi8ng a monthly income from disability, Social Security, retirement or unemployment, they
will be required to contribute 35% of that income monthly to the program.

I. Applicants are required to have read and become familiar with the following (initial each one):

1. Student Guidelines

2. Medical Policies

3. Student Discipline Policies

4. Student Grievance Procedure

By my initial, I acknowledge that I have reviewed each segment of the Induction Packet.

Applicant's Signature: Date:

Printed Name:

12
 BACKGROUND INVESTIGATION CONSENT
I, hereby authorize Bridge Recovery House and/or its
agency to make an independent investigation of my background, references, character, past
employment, education, credit history, criminal or police records, including those maintained
by both public and private organizations and all public records for the purpose of confirming
the information contained on my Application and/or obtaining other information which may be
material to my qualifications, employment now and, if applicable, during the tenure of my
employment with Bridge to Recovery House.

I release Bridge Recovery House and/or its agents and any person or entity, which provides
information pursuant to this authorization, from any and all liabilities, claims or law suits in
regard to the information obtained from any and all of the above reference sources used.

The following is my true and complete legal name and all information is true and correct to the
best of my knowledge:

Full Name Other Names Used

How Long?
Present Address

State Zip Code

City

How Long?
Former Address

State Zip Code

City

Social Security Number Driver's License Number & State

*Date of Birth

Date
Signature
only, and is in no manner
*NOTE: The above information is required for identification purposes
as qualification for employment. Bridge Recovery House is an Equal Opportunity Employer, and
does not discriminate on the basis of Sex, Race, Age (40 and over), Handicap or National Origin.
 Christian Conciliation and Arbitration Agreement
In consideration of the following terms and provisions, and the valuable consideration the
receipt of which I acknowledge, the undersigned parties hereby agree as follows:

They accept the Bible as the inspired word of God. They believe that God desires that they
resolved their dispute with one another within the Church and that they be reconciled in their
relationships in accordance with the principles stated in I Corinthians 6:1-8, Matthew 5:23-24,
and Matthew 18:15-20.

Accordingly, the undersigned parties hereby agree that any dispute or controversy arises
between them and is not resolved in private meetings between the parties pursuant to
Matthew 5:23-24 and 18:15, then the dispute or controversy will be settled by biblically based
mediation and, if necessary, legally binding arbitration, in accordance with the Rules of
Procedure for Christian Conciliation (Rules) of the Institute for Christian Conciliation, a division
of Peacemaker Ministries (rules available at www.HisPeace.org ). The undersigned parties
agree that these methods shall be the sole remedy for any dispute or controversy between
them and to the full extent permitted by applicable law, expressly waive their right to file a
lawsuit in any civil court against one another for such disputes, except to enforce arbitration
decision, or to enforce this dispute resolution agreement. Any mediated settlement
agreement, or arbitrated decision hereunder shall be final and binding, and fully enforceable
according to its terms in any court of competent jurisdiction.

Signature Date

Witness Date
 What to Bring

Documents for Admission:

• Driver's License or State Issue Picture ID

• Social Security Card

• Birth Certificate (certified copy) — if available

• Medical Records — if applicable

Other Items You May Bring:

You should bring the following items if you have them. If you do not have them and do not have the means to purchase
them, do not worry. We may be able to provide some of these items at no cost to you.

Please note: Closet and storage space is limited. Do not bring more than what is listed below. All items must fit into
two suitcases.

CLOTHING: Pens/pencils
- 5 pairs of Work Pants/Jeans - Index cards — used for memorizing scripture
- 7 T-shirts (no obscene or inappropriate logos) Loose leaf paper
- Socks Highlighter
- Underwear
5 Collared button down shirts
- 5 Polo Shirts
- 1 Sweater MISCELANEOUS
- 2 Pair of Dress Pants - 2 Bibles —1 NIV suggested
- 2 Pair of Dress Jeans - 1 Commentary
- 2 Pair Sweat Pants - 1 Devotional
- 2 Hoodies - 1 Personal Book (Spiritual Based)
- 1 Coat - Envelopes/Stamps
- Belt Stationary
- 2 Hats/Caps
1 Shower shoes/flip flops
1 Pair Work Shoes/Boots
- 2 Pair Tennis Shoes (1 for use in phase 2 gym
only)
- 2 Pair Dress shoes (brown/black high or low
top, dress
or cowboy boots)

TOILETRIES:
- Soap - Deodorant
Shampoo - Razor, Shaving
Comb/brush Cream
- Toothbrush — Toothpaste - Blow dryer
- 3 Towels , 3 Washcloths - Pillow
SCHOOL SUPPLIES:
- Spiral Notebooks
 ITEMS YOU MAY NOT BRING

• More than two suitcases of items

• Cassette Players — cassettes

• CD Players — CD'S

• VCRs —VHS Tapes

• DVD Players — DVDs

• iPods, iPads, MP3 Players, etc.

• Headsets

• Video Games

• Radios

• Televisions

• Computers or Tablets

• Cell Phones

• Magazines, newspapers, or other printed articles

• Weapons of any kind

• Tools of any kind

• Recreation Equipment

• Playing Cards, Dice, Games

• Illegal Drugs, Drug Paraphernalia

• Alcohol or Tobacco Products

• Personal Vehicle

• Food, Candy, or Drink of any kind

• Fan (one is provided for each room)

• Rug

We recognize the importance of music, games, recreation, entertainment, and other activities in the
proper growth and development of our residents. We will provide the necessary equipment and the
opportunity for these activities.
These lists are not comprehensive nor all inclusive.
All medication must be approved by the Induction Coordinator before allowed in Bridge Recovery
House. These lists will be updated on an ongoing basis.
8/5/2018

NOT ALLOWED MEDICATIONS

Medication Name Reason/Brand Name

Adderall
Alprazolam
Ambien Sleep aid
Amitriptyline
Anatriplene
Ativan
Baclofen Muscle relaxer
Buspar Vanspar, Busiprone
Buispirone Effects your thought patterns, causes drowsiness
Clonzeapam Depression
Cogentin Makes you prone to heat strokes, it's a benzo
Concerta ADHD
Cyclobenzaprine Generic Flexeril
Diazepam
Doxylamine Sleep-aid — Unisom
Flexeril Muscle relaxer
Fluoxetine Prozac
Gabapentin Generic Neurontin
Gabitril Epilepsy, bi-polar
Geoden
Haldol Schizophrenia
Hydrocodone
Imipramine Sleep aid, depression
Invega Schizo-psychotropic
Klonopin Depression
Librium
Liorecel Muscle relaxer
Loracet
Lorazapam
Methylphenidate Concern aka Ritalin
Methylphenidate ADHD
Mobic
Neutontin Pain, Bi-polar, Epilepsy
Norco
Oxycodone
Percocet Narcotic pain killer
Phenergan
Promethazine

Page 1 of 2
Provigil To stay awake, used to treat narcolepsy
Prozac
Quetiapine Fumarate Serequel
Remeron Sleep aid
Restoril Benzo- and sleep aid
Risperdal Schizophrenia
Risperdone
Ritalin Methylphenidate
Robaxin Muscle Relaxer
Serequel Schizophrenia, Bi-polar
Soma
Suboxone
Symbyax Olanzapine & Fluoxetine
Temazepam
Tizanidine Muscle relaxer
Tramadol
Trazadone
Trihexphenidyl Tremors/Parkinsons
Ultram
Unisom Sleep-aid
Valium
Vanspar Anxiety
Vyvanse ADHD
Xanax
Zanaflex Tizanidine
Ziprasidone Geodon
Zolpidem Sleep aid
Zyban Stop smoking

Page 2 of 2
These lists are not comprehensive nor all inclusive.
All medication must be approved by the Induction Coordinator before allowed in Bridge Recovery
House. These lists will be updated on an ongoing basis.
8/5/2018

ALLOWED MEDICATIONS

MOicatiort Name Reasolinkaild Name

Abilify Bi-polar, anger
Accuneb Albuterol
Acetaminophen Pain
Albuterol Asthma
Aldactone Diuretic
Allegra Antihistamine
Amoxicillin Antibiotic
Aripiproazole Abilify
Aripiproazole COPD
Atenolol Heart, HPB
Bactrim Antibiotic
Benicar High Blood Pressure
Carbamazepine Tegretol
Cefprozil Antibiotic
Cefzil Antibiotic
Celexa Depression-dtr monitored
Citalopram Hydrobromide Celexa
Clonidine HCL High Blood Pressure
Coumadin Blood Thinner
Cymbalta Depression, anxiety
Depakote Bi-polar
Diltiazem Hypertension
Divalproex Depakote
Doxycycline Antibiotic
Effexor Depression
Enalapril Maleate Hypertension
Epzicom HIV
Fetzima Deppression
Flomax Alpha Blocker
Fluvoxamine Luvox
Furosemide Lasix
Hydrochlorothiazide Diuretic
Hydroxyzine Vistaril
Ibuprophen 600/800 Pain
Inderal Tremors, hypertension, heart conditions
Indomethacin Anti-inflammatory
Labetalol Hypertension
Lamictal Bi-polar, epilepsy

Page 1 of 3
Lasix Diuretic
Latuda Depression, Bi-polar
Latuda Bi-polar, Schizophrenia
Levothyroxine Hypothyroidism
Lexapro Depression
Lipator Blood Cholesterol
Lisinopril Blood Pressure
Lithium Depression, Bi-polar (high risk)
Lurasidone Latuda
Luvox OCD, depression
Lyrica Pain, Seizures
Meloxicam Anti-inflammatory
Mirtazapine Depression, Anxiety
Nexuyn Acid reflux, heart burn
Nitroquick Heart Attack
Norvasc Hypertension, blood pressure
Olanzapine Zyprexa
Omeprazole Prilosec
Paroxetine OCD, depression
Paxil Paroxetine
Penicillin Antibiotic
Piroxicam Anti-inflammatory
Plavix Stroke
Prilosec Acid reflux, heart burn
Pristiq Depression
ProAir Albuterol
Propanolol Beta Blocker
Qvar COPD
Rantadine Acid Reflux
Sertraline Zoloft
Simvastatin Cholesterol
Spironolactone Aldactone
Strattera ADHD
Sulfameth/Trimeth DS Antibiotics
Sulfatrim Sulfameth/Trimeth DS
Tegretol Seizure, Bi-polar, Depression
Topamax Seizures, Migraines, Bi-polar
Toprol Hypertension
Trileptal Epilepsy
Venlafaxine Effexor
Vibracin Doxycycline
Vistaril Antihistamine
Vytorin Cholesterol
Warfarin Blood Thinner
Welibutrin Depression
Xyzal Antihistamine

Page 2 of 3
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