Personal Medication Form - Legacy Health
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2Personal Medication Form
Name: __________________________ Date of birth: ________ Date form last updated: __________
Your complete medication history is important to your physicians and to the hospital. Please fill out this form and
bring it with you anytime you go to the doctor’s office or to the hospital. If you are scheduled for a Pre-Surgical
Services appointment, make a trip to the Emergency Room, or are coming directly to the hospital – Remember to
bring this completed form!!
If for some reason you are unable to fill out this form, please bring in a bag of all of the medications (in their
original containers) that you are currently taking.
Allergies:
Are you allergic to medications, iodine, food, tape, or latex?
List each substance you are allergic to and the reaction you experienced.
Allergy
Reaction
Allergy
Reaction
Vaccines:
Check one box for each vaccine.
Tetanus
Pneumonia
Influenza (Flu)
Pediatric (for child)
Within past 10 years
Within past 5 years
Within the past year
Up-to-date
Unknown
Unknown
Unknown
Unknown
Medications:
Please list all prescription and non-prescription medications, herbals,
eye drops, nutritional supplements, inhalers, etc that you use.
Dose
Route
Purpose
Name of medicine
Directions
(mg, units,
(by mouth,
Why do you
puffs)
eye drops)
take it?
List additional meds AND any medications that you have recently stopped – on the back
254129 (4/06)
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