My Medication Record Template printable pdf download

My Medication Record Template

My Medication record

LOGO

Name:________________________________________________________________ Birth date: _______________________________

Include all of your medications on this reord: prescription medications, nonprescription medications, herbal products, and other dietary supplements.

Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.

Drug

When do I take it?

Take for...

Start Date Stop Date

Doctor

Special Instructions

Name

Dose

Morning

Noon

Evening

Bedtime

This sample Personal Medical Record (PMR) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient

(or other user) should not, under any circumstances, solely rely on, or act on the basis of, the PMR or the information therein. If he or she does so, then he or she does so at his or her

own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the PMR is not a substitute for obtaining professional healthcare

advice or treatment. This PMR may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists

Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.