Universal Medication Form
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1
2UNIVERSAL MEDICATION FORM
Fold this form and keep it in your wallet/purse.
Date form started:
Name:
Address:
Phone Number:
Birth Date:
Emergency Contact/Phone numbers:
IMMUNIZATION RECORD
(Record the date/year of last dose taken, if known)
TETANUS
FLU VACCINE(S)
PNEUMONIA VACCINE
HEPATITIS VACCINE
OTHER
Allergic To /Describe Reaction:
Allergic To /Describe Reaction:
Prescription and over-the-counter medications
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
(examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as
n
eeded (example: nitroglycerin).
DIRECTIONS:
Notes: Reason for taking /
NAME OF MEDICATION /
DATE
How do you take this medication?
DOSE
Doctor Name
(ex: How many times a day, by mouth, injection, etc.)
Patient Signature__________________________________________ Date: _________ Time: _________
Refer to back of form for directions, benefits of using the form, and how to get more copies.
F ORM NO. 7220
(04/10)
Page _______ of _______
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Parent category: Medical