Universal Medication Form - Owensboro Health
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1
2“UNIVERSAL MEDICATION FORM”
Fold this form and keep it in your wallet/purse
HOW DOES THIS FORM HELP YOU?
I. This form helps you and your family members remember all of the
medicines you are taking.
II. This form provides your doctor(s) and others with a current list of
ALL
of
your medicines
, including the herbals
(example: nitroglycerin)
(examples:
, vitamins, and over-the-counter medicines
ginseng, gingko)
(examples:
you take.
aspirin, antacids)
To Our Valued Patients:
1. ALWAYS KEEP THIS FORM WITH YOU. You may
5. In the NOTES
want to fold it and keep it in your wallet along with
column, WRITE
your driver's license. Then it will be available in case
DOWN THE NAME OF THE DOCTOR who told you
of an emergency.
to take the medicine(s). You may also write down
why you are taking the medicine (Examples: high
2. WRITE DOWN ALL OF THE MEDICINES you are
blood pressure, high blood sugar, high cholesterol).
taking and list all of your allergies.
6. When you are discharged from the hospital,
3. TAKE THIS FORM TO ALL DOCTOR VISITS, WHEN
someone will talk with you about WHICH
YOU GO FOR TESTS AND ALL HOSPITAL VISITS.
MEDICINES TO TAKE AND WHICH MEDICINES TO
STOP TAKING. Since many changes are often
4. WRITE DOWN ALL CHANGES MADE TO YOUR
made after a hospital stay, a new form may be filled
MEDICINES on this form. If you stop taking a
out. When you return to your doctor, take your
certain medicine, draw a line through it and write
most current form with you. This will keep
the date it was
everyone up-to-date on your medicines.
stopped. If help is
needed, ask your
Doctor, Nurse,
Pharmacist, or family
member to help you to
keep it up-to-date.
For copies of the UNIVERSAL MEDICATION FORM, visit:
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