Universal Medication Form - Cannon Memorial Hospital
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2UNIVERSAL MEDICATION FORM
Fold this form and keep it in your wallet
Date form started:
Name:
Address:
Phone Number:
Birth Date:
Emergency Contact/Phone numbers:
IMMUNIZATION RECORD
(Record the date/year of last dose taken, if known)
TETANUS
FLU VACCINE(S)
PNEUMONIA VACCINE
HEPATITIS VACCINE
OTHER
Allergic To /Describe Reaction:
Allergic To /Describe Reaction:
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: prescription and over-the-counter
medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko).
Include medications taken as needed (example: nitroglycerin).
Notes: Reason
DIRECTIONS:
NAME OF MEDICATION /
DATE
for taking /
DATE
Use patient friendly directions.
DOSE
STOPPED
(Do not use medical abbreviations.)
Doctor Name
Refer to back of form for directions, benefits of using the form, and how to get more copies.
(02/04)
Page _______ of _______
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