Medical Card Form (Page 2 of 2) in pdf

Medical Card Form Page 2

Personal Medicine Record for:_______________________________________________________

•

Use a pencil.

•

Do not list medicines I will take for less than two weeks (example: antibiotics).

•

List

all medicines I take, including prescriptions, eye drops,

inhalers/nebulizers, oxygen, creams and ointments, birth control pills, etc.

Date

Medicine

How much?

How often

What is it for?

Doctor who

added or

(Strength/

do I take it?

prescribed it

changed

Dosage)

Over-the-Counter Medicines (medicines you can buy without a doctor’s order):

(Check all that you use regularly.)

Allergy medicine, antihistamines

Cold/cough medicines

Laxatives

Pain, headache or fever medicine

Antacids (for heartburn or stomach)

Diet pills

Sleeping pills

Other (List):

Aspirin

Herbals, dietary supplements, hormones

Vitamins, minerals

Always:

Keep this card with you.

Keep insurance cards with this card.

Give this card to your doctor to be checked and updated.

Use the same pharmacy if you can.

Always give this card to your pharmacist when you get a new medicine.

Medical Card Form Page 2