My Medication Log printable pdf download

My Medication Log

My Medication Log – Keep it Handy

• List all prescriptions, over-the-counter drugs, vitamins and herbs.

Date: _________________________

• Bring this to every doctor’s appointment and if you go to the emergency room or hospital.

How Much and How Often?

Reminder:

This Medicine

When do I take it?

Name and Dose of

Morning

Noon

Evening

Bedtime

is for

Your Medicine

my_____________

Example:

Simvastatin 40 mg

High cholesterol

1 pill

After I brush my teeth

If you have any problems with your medicine – do not wait. Talk to your health care provider right away.

Name of Primary

Primary Care Provider

Patient Name: _____________________________

Care Provider: _________________________________

Phone Number: ________________________

THE NEW YORK CITY DEPARTMENT

Keep Your Heart Healthy:

of HEALTH and MENTAL HYGIENE

A Key Step to a

Michael R. Bloomberg, Mayor

Healthier New York

Thomas R. Frieden, M.D., M.P.H., Commissioner

nyc.gov/health

My Medication Log