Universal Medication Form - Cannon Memorial Hospital Page 2
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2UNIVERSAL MEDICATION FORM
Patient:
1. ALWAYS KEEP THIS FORM WITH YOU. You may want to fold it and keep it in your wallet
along with your driver’s license. Then it will be available in case of an emergency.
2. Write down all of the medicines you are taking and list all of your allergies.
3. Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
4. WRITE DOWN ALL CHANGES MADE TO YOUR MEDICINES on this form. If you stop taking a
certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask
your Doctor, Nurse, Pharmacist, or family member to help you to keep it up-to-date.
5. In the NOTES column, write down the name of the doctor who told you to take the medicine(s).
You may also write down why you are taking the medicine (Examples: high blood pressure,
high blood sugar, high cholesterol).
6. When you are discharged from the hospital, someone will talk with you about WHICH MEDICINES
TO TAKE AND WHICH MEDICINES TO STOP TAKING. Since many changes are often made
after a hospital stay, a new form should be filled out. When you return to your doctor, take your
new form with you. This will keep everyone up-to-date on your medicines.
HOW DOES THIS FORM HELP YOU?
1. This form helps you and your family members remember all of the medicines you are taking.
2. Provides your doctor(s) and others with a current list of ALL of your medicines. Doctors need
to know the herbals, vitamins, and over-the-counter medicines you take!
3. Helps you –concerns may be found and prevented by knowing what medicines you are taking.
CAROLINA MEDICAL REVIEW
sm
South Carolina
Hospital
SC MEDICAL
Association
South Carolina Society of
ASSOCIATION
Health System Pharmacists
For copies of the UNIVERSAL MEDICATION FORM visit the South
Carolina Hospital Association web site at
Developed by AnMed Health and South Carolina Hospital Association 2004
(02/04)
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