Universal Medication Form - Owensboro Health Page 2
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1
2Know Your Medicines:
“UNIVERSAL MEDICATION FORM”
Fold this form and keep it in your wallet/purse
Date form started:
MY Personal Information:
1
Name:
Street Address:
City/State:
Zip Code:
Phone:
Birth Date:
/ /
Physicians:
MY Emergency Contact/Phone Numbers:
2
MY Immunization Record:
3
(Record the date/year of last dose taken, if known)
TETANUS:
FLU VACCINE(S):
PNEUMONIA VACCINE:
HEPATITIS VACCINE:
OTHER:
Allergies? Describe reaction(s):
MY MEDICATION Information:
4
LIST
ALL
MEDICINES YOU ARE CURRENTLY TAKING:
Prescription medicines (example: nitroglycerin), including the herbals (examples: ginseng, gingko), vitamins,
and over-the-counter medicines (examples: aspirin, antacids) you take.
DIRECTIONS:
NOTES: Reason for taking/
(No abbreviations)
DATE:
NAME OF MEDICATION/DOSE:
DATE STOPPED:
Doctor Name
Use patient friendly directions.
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