Medication List Template Page 2
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4Medication List
Share your Medication List with all your healthcare providers. Keep it with you at all times.
Name:
Family Doctor’s Name:
Medical History:
*
diabetes
____________________________________
____________________________________
*
high blood pressure
Address:
____________________________________
*
heart disease
*
____________________________________
Phone: _______________________________
breathing problems
*
other medical problems (list below)
____________________________________
Emergency Contact:
____________________________________
____________________________________
____________________________________
____________________________________
Date of Birth: (yyyy/mm/dd)
____________________________________
____________________________________
____________/____________/__________
Phone: _______________________________
____________________________________
Gender:
_____ M _____ F
Secondary Emergency Contact:
____________________________________
Alberta Personal Health Card #:
____________________________________
____________________________________
___ ___ ___ ___ ___ - ___ ___ ___ ___
____________________________________
My allergies to medications and what happens to
me when I take these:
Medical Plan #: (e.g., Alberta Blue Cross)
Phone: _______________________________
____________________________________
____________________________________
Pharmacy Name:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Pharmacy Number:
____________________________________
____________________________________
____________________________________
List the medications you take on page 3.
____________________________________
Adapted from ‘It’s Safe to Ask Medication Card’ Manitoba Institute for Patient Safety.
To find out more, visit
If it’s on the list, it won’t be missed
1-866-408-5465 (LINK)
or call Health Link Alberta:
toll-free.
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