My Medication List printable pdf download

My Medication List

Date: _________________________

My Medication List

Hospitals and healthcare providers may not have a current list of your medications. Take your

medication list to all doctor visits. Keep it in your wallet or purse so it is readily available in case of an

emergency. Keep your information and medication list up-to-date.

Name ___________________________________________________________________________

Date of Birth ___________________________ Height _______________ Weight _______________

Allergies

______________________________________________________________

(drugs and food)

Address _________________________________________________________________________

Phone Number _______________________________Cell Phone ____________________________

Primary Doctor _________________________________Phone# ____________________________

Pharmacy _____________________________________Phone # ____________________________

Emergency Contact ________________________________________________________________

(Name)

(Relationship)

(Phone #)

List all prescription and over-the-counter medicine, herbs, vitamins, dietary supplements, etc.

Drug Name

Dose

When do I take it?

Why do I take it?

Physician

Start date

My Medication List