Medication Log (Page 2 of 2) in pdf

Patient Information

Medication Allergies

_________________________________________

Name:__________________________________

Date of Birth:____________________________

Medical Record #

We are Partners in Safety

___________________

What Can You Do?

Home Address:_________________________

______________________________________

Vaccinations

(Please note the dates of immunization)

Phone:________________________________

Please carry this

Physician:______________________________

Influenza:_________________________________

list of your home

________________________________________

Phys Phone:___________________________

Pneumonia:______________________________

medications with

Pharmacy:_____________________________

Tetanus:_________________________________

you at all times.

Other:___________________________________

Pharm Phone:____________________________

Emergency Contact:_______________________

Over-the-Counter Medications

 Allergy Relief/Antihistamines

Medication errors are a primary cause of

_____________________________________

 Cough/Cold Medications

complications in healthcare.

 Aspirin/Other Pain

Medical History

Emergencies can occur and this information is

 Antacids

critical for the healthcare provider to avoid

 Laxatives

1)______________________________________

reactions related to medications that may be

 Sleeping Pills

2)____________________________________

 Diet Pills

new for you during your stay at our hospital.

3)_____________________________________

 Herbal/Dietary

/ (301) 609-4000

 St. John’s Wort

4)____________________________________

 Ginko Biloba

5)____________________________________

 Other (list on Medication Log)

Patient Information

Medication Allergies

_________________________________________

Name:__________________________________

Date of Birth:____________________________

Medical Record #

We are Partners in Safety

What Can You Do?

___________________

Home Address:_________________________

______________________________________

Vaccinations

(Please note the dates of immunization)

Please carry this

Phone:________________________________

list of your home

Physician:______________________________

Influenza:_________________________________

________________________________________

Phys Phone:___________________________

medications with

Pneumonia:______________________________

Pharmacy:_____________________________

you at all times.

Tetanus:_________________________________

Other:___________________________________

Pharm Phone:____________________________

Emergency Contact:_______________________

Over-the-Counter Medications

Medication errors are a primary cause of

 Allergy Relief/Antihistamines

complications in healthcare.

_____________________________________

 Cough/Cold Medications

 Aspirin/Other Pain

Emergencies can occur and this information is

Medical History

 Antacids

critical for the healthcare provider to avoid

 Laxatives

1)______________________________________

reactions related to medications that may be

 Sleeping Pills

new for you during your stay at our hospital.

2)____________________________________

 Diet Pills

3)_____________________________________

 Herbal/Dietary

/ (301) 609-4000

 St. John’s Wort

4)____________________________________

 Ginko Biloba

5)____________________________________

 Other (list on Medication Log)

Patient Information

Medication Allergies

_________________________________________

Name:__________________________________

Date of Birth:____________________________

Medical Record #

We are Partners in Safety

What Can You Do?

___________________

Home Address:_________________________

______________________________________

Vaccinations

Please carry this

(Please note the dates of immunization)

Phone:________________________________

Influenza:_________________________________

list of your home

Physician:______________________________

________________________________________

Phys Phone:___________________________

medications with

Pneumonia:______________________________

Tetanus:_________________________________

Pharmacy:_____________________________

you at all times.

Other:___________________________________

Pharm Phone:____________________________

Emergency Contact:_______________________

Over-the-Counter Medications

Medication errors are a primary cause of

 Allergy Relief/Antihistamines

complications in healthcare.

_____________________________________

 Cough/Cold Medications

 Aspirin/Other Pain

Emergencies can occur and this information is

 Antacids

Medical History

critical for the healthcare provider to avoid

 Laxatives

1)______________________________________

reactions related to medications that may be

 Sleeping Pills

new for you during your stay at our hospital.

2)____________________________________

 Diet Pills

 Herbal/Dietary

3)_____________________________________

/ (301) 609-4000

 St. John’s Wort

4)____________________________________

 Ginko Biloba

5)____________________________________

 Other (list on Medication Log)

Medication Log Page 2

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