Fillable My Medication List Template printable pdf download

My Medication List Template

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My Medication List

Your healthcare providers at Harney District Hospital ask you to

be an active member of your healthcare team. Please keep

your medication list up to date and with you at all times.

My Name:___________________________________________Date List Updated:___________________

My Pharmacy Name:______________________________Pharmacy Phone:________________________

My Birthdate:__________________________My Phone Number:_________________________________

Emergency Contact/Phone:_______________________________________________________________

My Allergies

and Drugs to Avoid/Adverse Reactions:

________________________________________________________________

Current Medications: List all medications you are taking; include over-the-counter preparations (like

aspirin, pain relievers, antacids, vitamins, herbals)

Medication:___________________________________________Dosage:__________________________