Universal Medication Form
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2Name:
UNIVERSAL MEDICATION FORM
(Always keep this form with you. Instructions on page 4.)
Name
Date of Birth
Sex (circle one)
Height
Weight
Male
Female
Susan Q. Public
01/01/42
5 ft 4 in
155 lb
Address
Phone Number(s)
Emergency Contact
Home: 215-222-1222
Name: John T. Public
123 Main St.
Work:
Relation: husband
Anywhere, PA 00000
Mobile:
Phone: 215-222-1224
Allergies (please describe reaction)
Penicillin (severe rash)
Iodine/Shellfish (rash and severe nausea)
Codeine (itch and rash, constipation)
Doctor / Dentist / Other Prescriber’s Name
Phone Number
Type of Practitioner / Reason for Seeing
R. Smith, DO
215-555-1234
Primary Care / Internist
M. Miller, CRNP
215-555-1111
Well-woman care
D. Jones, MD
215-555-1237
Cardiologist
Pharmacy Name
Phone Number
Street/City/State
Immunizations (Date of Last Dose)
ABC Pharmacy
Philadelphia Pike, Anywhere, PA
□ Tetanus:
□ Pneumonia Vaccine:
□ Flu Vaccine:
Additional Information / Comments
□ Hepatitis Vaccine:
I have trouble swallowing large pills and I need easy to open containers.
□ Other:
Page 1 of ___
Date Updated:
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