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Medication Record

This document is a template for a personal medication record. It includes sections for a person's personal information, emergency contacts, primary care physician, pharmacy, other physicians, medical conditions, allergies, and a table to list all medications including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. The template notes that the record should be shared with doctors and pharmacists, kept up-to-date, and used to track any changes to medications, doses, or when they are started or stopped.

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api-283985063
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119 views

Medication Record

This document is a template for a personal medication record. It includes sections for a person's personal information, emergency contacts, primary care physician, pharmacy, other physicians, medical conditions, allergies, and a table to list all medications including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. The template notes that the record should be shared with doctors and pharmacists, kept up-to-date, and used to track any changes to medications, doses, or when they are started or stopped.

Uploaded by

api-283985063
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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My Personal Medication Record

My Personal Information
Name: ______________________________________________
Date of Birth: ________________________________________
Phone Number: ______________________________________

Emergency Contact
Name: ______________________________________________
Relationship & Phone Number: ________________________

Primary Care Physician


Name: ______________________________________________
Phone Number: ______________________________________

Pharmacy/Drugstore

Pharmacist: __________________________________________

How to use this Guide:


Use this record to keep track of your
medications, including prescription drugs,
over-the counter (OTC) drugs, herbal
supplements, and vitamins.
Share the information with your doctors
and pharmacists at all visits.
Keep it always with you.
Use a pencil.

You should review


this record when:
Starting or stopping a new medicine.
Changing a dose.
Visiting your doctor or pharmacist.

Last updated:

____ /____ /____

Phone Number: ______________________________________

Other Physicians

My Medical Conditions

Name: ______________________________________________
Specialty: ____________________________________________

____________________________________________________

Phone number: ______________________________________

____________________________________________________

Name: ______________________________________________

____________________________________________________

Specialty: ____________________________________________

____________________________________________________

Phone number: ______________________________________

____________________________________________________

Name: ______________________________________________

____________________________________________________

Specialty: ____________________________________________

____________________________________________________

Phone number: ______________________________________

____________________________________________________

My Allergies

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________
In cooperation with the SOS Rx Coalition
D18358 (407)

What Im
Taking
Reason for Use

Form
(pill, patch,
liquid, injection,
etc.)

Dosage

How Much
& When

Use
(regularly or
occasionally)

Start/Stop
Dates
(1/05/05 3/05/05)
(1/01/94 ongoing)

Notes or Special Directions

*Be sure to include ALL prescription drugs, over-the-counter drugs, vitamins, and herbal supplements.

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