My Medication List printable pdf download

My Medication List

ü Keep this list up-to-date with the prescription medications, over-the-counter medications, vitamins, supplements and topical products you use.

ü Please take this list with you to any doctor appointments or when you go to the hospital or emergency room.

Date:_____________________

Name:_____________________________________________________________________Date of birth:______________________________

Allergies:___________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

My doctors and their phone numbers:_____________________________________________________________________________________

___________________________________________________________________________________________________________________

Pharmacies I use and their phone numbers:________________________________________________________________________________

___________________________________________________________________________________________________________________

Medication Name

Tablet/Capsule Strength

Dose I take

Time(s) of day taken

Reason for use

Example Medication

2 mg tablet

1/2 tablet (1 mg) by mouth Every morning

Blood pressure

My Medication List