Sonoran Medical Centers
Patient Medication, Vitamin and Supplement Log
for (name) __________________________________ DOB: ________________ Today's Date: ________________
Include prescription medications, over-the-counter medications, vitamins and herbal supplements
Pharmacy Name: ___________________________________________ Phone: ___________________________________
Pharmacy Cross Streets: ________________________________________
Mail Order Pharmacy Name: ________________________________________ Mail Order ID #: ________________________________________
Start
Name of Medicine
Dose
# taken
When do you take it?
What's it for?
Size/color/
Prescribed by
Local Pharm
Important Comments
With food?
Date
per day
shape
Brand Name/Generic Name
(mg, units)
Morning/night, after meals
Y or N
Purpose
Provider's name
or Mail order
(danger signs, side effects, interactions)
Please bring this updated form with you to all of your medical office visits. If your medicines change, please tell your medical provider.
Check the detailed drug sheets provided by the pharmacy with each medication, or talk to your doctor about possible side effects, danger signs and interactions.
Allergies to: ___________________________________________________________________________________________________________________________________
Other Medical Providers that you are seeing (please include dentist and eye doctor):
Last Seen
Provider name
Specialty
Problem they are treating
Comments