My Medication List

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My Medication
List
Keep this list updated any time your prescribed medication, dosage, or frequency changes. Keep a copy in your
emergency kit. Always take your medication list to doctor’s visits and to the hospital. Complete a second page if
you are on more than seven medications.
Name: _______________________________________________________________________________________
Date Completed: _____________________________________________________________________________
Completed by: _______________________________________________________________________________
MeDiCatioN
Dosage
FrequeNCy
Notes
Include name brand and
List the amount
How many times
Include if this medication should
generic name, if applicable
of each dose
per day medication
be taken with food, taken on an
(e.g., # mg)
is taken
empty stomach, or other special
instructions
Provided in partnership by the Department of Health and
Mental Hygiene Office of Preparedness and Response and the
Maryland-National Capital Homecare Association

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