My Medicine List

Fold this form and keep it with you

Patient First Name

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Patient Last Name

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Date of Birth

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Allergic To:(Describe Reaction)

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Emergency Contact / Phone Numbers

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Doctors

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Pharmacies, other sources:

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Immunization Record(Record the date/year of last dose taken)

Flu Vaccines(s):

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Pneumonia Vaccine

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Tetanus:

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Hepatities Vaccine:

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Other:

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List all medicines you are currently taking

List all medicines you are currently taking. Include prescriptions (examples: pills, inhalers, creams, shots), over-the-counter medications (examples: aspirin, antacids, vitamins) and herbals (examples: ginseng, gingko). Include medications taken as needed(example: nitroglycerin, inhalers).

START DATE

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NAME OF MEDICATION

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DOSE

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DIRECTIONS (How do you take it? When? How Often?)

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DATE STOPPED

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NOTES(Reason for taking?)

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START DATE

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NAME OF MEDICATION

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DOSE

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DIRECTIONS(How do you take it? When? How Often?)

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DATE STOPPED

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NOTES(Reason for taking?)

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START DATE

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NAME OF MEDICATION

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DOSE

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DIRECTIONS(How do you take it? When? How Often?)

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DATE STOPPED

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NOTES(Reason for taking?)

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START DATE

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NAME OF MEDICATION

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DOSE

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DIRECTIONS(How do you take it? When? How Often?)

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DATE STOPPED

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NOTES(Reason for taking?)

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START DATE

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NAME OF MEDICATION

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DOSE

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DIRECTIONS(How do you take it? When? How Often?)

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DATE STOPPED

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NOTES(Reason for taking?)

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Directions for My Medicine List

ALWAYS KEEP THIS FORM WITH YOU. You may want to fold it and keep it in your wallet along with your driver's license. Then it will be available in case of an emergency.
Write down all of the medicines you are taking and list all of your allergies. Add information on medicines taken in clinics, hospitals and other health care settings - as well as at home.
Take this form with you on all visits to your clinic, pharmacy, hospital, physician, or other providers.
WRITE DOWN ALL CHANGES MADE TO YOUR MEDICINES on this form. When you stop taking a certain medicine, write the date it was stopped. If help is needed, ask your doctor, nurse, pharmacist, or family memeber to help you keep it up to date.
In the "Notes" column, write down why you are taking the medicine (Examples: hign blood pressure, high blood sugar, high cholestrol).
When you are discharged from hospital, someone will talk with you about which medicines to take and which medicines to take and which medicines to stop taking. Since many changes are often made after a hospital stay, a new list may be filles out. When you return to your doctor, take your list with you. This will keep everyone uptodate on your medicines.

How does this form help you?

This form helps you and your family members remember all of the medicines you are taking. Consider sharing your completed list with adult children or other medical decision makers.
It provides your doctors and other providers with a current list of ALL of your medicines. They need to know the herbals, vitamins and other providers can prevent potential health problems triggred by how different medicines interact.
With this information, doctors and other providers can prevent potential health problems, triggered by how different medicines interact.

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