My Medication List

My name:____________________________________ My birth date:____________________


My emergency contact

Name:________________________________________ Phone:__________________________


Names and phone numbers of my health care providers

Name:________________________________________ Phone:__________________________

Name:________________________________________ Phone:__________________________

Name:________________________________________ Phone:__________________________


Name and phone number of my pharmacy

Name:________________________________________ Phone:__________________________


My allergies (medicines, foods, and others, such as bee stings or latex)

I am allergic to_________________________. My reaction is___________________________.

I am allergic to_________________________. My reaction is___________________________.

I am allergic to_________________________. My reaction is___________________________.

(If you need more space to write your allergies, use the back of this page.)


My health problems _________________________________________________________________________________
___________________________________________________________________________

My medicines

Include ALL your medicines, even over-the-counter (OTC), vitamins, and supplements. When you start taking a new medicine, write the date you start. If you stop taking a medicine, cross it off and write the date you stop. Keep this form with you. Bring it to office visits, the pharmacy, or if you get admitted to the hospital.

Name of medicine
(start or stop date)

Reason I take it

Dose

When I take it

What it looks like

Example: Aspirin (started 10-16-12)

For my heart

81 mg (1 pill)

Once a day

White, round
















































































































































































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