Blood Pressure Medication Information Form printable pdf download

Blood Pressure Medication Information Form

BLOOD PRESSURE MEDICATION INFORMATION FORM

FILL THIS FORM OUT WITH YOUR HEALTHCARE PROVIDER

1) Information about your prescribed blood pressure medicine:



Medicine Name #1:

____________________________________________



Number of pills per dose: ____________________________________________



Number of doses per day: ____________________________________________



When should you take your medicine: Morning, Afternoon, Evening (circle all that apply)



Are there any possible side effects: ______________________________________

2) If you are taking more than 1 blood pressure medication, fill in information below:



Medicine Name #2:

____________________________________________



Number of pills per day:

____________________________________________



Number of times per day: ____________________________________________



When should you take your medicine: Morning, Afternoon, Evening (circle one)



Are there any possible side effects: ______________________________________

3) Talk to your doctor or nurse about other medication(s) you are taking for other health issues:



Drug Name #1:

_____________________________, for __________________



Drug Name #2:

_____________________________, for __________________



Drug Name #3:

_____________________________, for __________________

SUMMARIZE YOUR MEDICATION REGIMEN

Medicine #1: I am taking _______________________(name of medicine), _______ number of pills,

________ time(s) per day in the morning/afternoon /evening.

Medicine #2: I am taking _______________________(name of medicine), _______ number of pills,

________ time(s) per day in the morning/afternoon /evening.

Blood Pressure Medication Information Form