My Medication Record Template

My Medication record

Name:________________________________________________________________ Birth date: _______________________________

Include all of your medications on this record: prescription medications, nonprescription medications, herbal products, and other dietary supplements.

Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.

Drug

When do I take it?

Take for...

Start Date Stop Date

Doctor

Special Instructions

Name

Dose

Morning

Noon

Evening

Bedtime

This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or

the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This

MAP may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

APhA and the NACDS Foundation encourage the use of this document in a manner and form that serves the individual needs of practitioners. All reproductions, including modified forms, should include the following statement: “This form is based on forms developed by the American

Pharmacists Association and the National Association of Chain Drug Stores Foundation. Reproduced with permission from APhA and NACDS Foundation.”