My Medication List printable pdf download

My Medication List

My Medication List – Keep It Handy

• List everything you take—prescriptions, over-the-counter drugs, vitamins, herbs and supplements.

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

• Don’t run out of your medicine—ask your doctor for a new prescription or get a refill from your pharmacist.

Date: _________________________

When Do I Take It and How Much?

This Medicine

I Will Remember to

Name and Dose

Morning

Noon

Evening

Bedtime

Is for

Take My Medicine

of My Medicine

My_____________

_________________

Example:

Hypertension

Hydrochlorothiazide 25 mg

1 pill

After I brush my teeth

(high blood pressure)

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

Patient Name:

Name of Primary Care Provider:

Name of Pharmacist:

Phone Number:

My Medication List