I am allergic or sensitive to
(please name the medication and describe the reaction)
*Remember to include any inhalers, sprays, creams, ointments, herbal remedies, vitamins and also any non-
prescription medicines you use regularly, such as paracetamol. Cross out any medications you no longer use.
Date of
Name of medication
How it
The
The dose
Do you take it
this
comes
strength
i.e. how much you
all the time or
The drug name or
entry
the brand name,
e.g. tablet,
e.g. a 10mg
take and how
only when you
whichever name you
inhaler,
tablet, a
often such as two
need it?
use yourself.
patch etc.
5mg patch.
tablets twice daily
This list should be maintained by the patient and brought into hospital for all attendances.
Do NOT file original in patient’s Healthcare Record.