Universal Medication Form Page 4
ADVERTISEMENT
1
2
3
4Name:
Universal Medication Form – Instructions for Use
ALWAYS KEEP THIS FORM WITH YOU. Keep it in your wallet. Give a copy to your emergency
•
contact, another family member or friend. Take it with you when you pick up prescriptions.
Doctor/dentist office. Take this form to ALL doctor visits, when you go for appointments, tests
•
and ALL hospital visits.
Allergies. List any reaction you have experienced from medicines that required you to stop taking
•
that medicine such as allergies or bad side effects. Also include any allergy to dye, food, or
insects, etc. Also write what happens to you if you are exposed to these things.
Doctor/dentist/nurse practitioner/other prescriber. List their names and a phone number in
•
case they need to be contacted about your medicines.
Pharmacy. List their names, phone number, and location in case there are questions.
•
List of medicines. Write the brand and generic name of each medicine, your dose, how often and
•
how (by mouth, under your tongue, injection, etc) you take it. If you stop taking a certain medicine,
draw a line through it and list the date you stopped taking it. If you need extra pages, remember to
write your name on each one. List all tablets, patches, drops, ointments, injections, etc. Include
prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any
medicine you take only on occasion or “as needed.” (like Motrin, Aleve, Tylenol, nitroglycerin).
Hospital visits. Always ask your nurse, pharmacist or doctor to help you update your list when
•
you leave the hospital. You need to know what medicines to take and what to stop taking. Bring
the updated form to any and all follow up appointments at your doctor’s office or hospital.
Page 4 of ___
Date Updated:
ADVERTISEMENT
0 votes
