My Medications List Template printable pdf download

IMMANUEL KANT 1724-1804

Science is organized knowledge.

Bring your medication list

Wisdom is organized life.

to every doctor visit!

My Medications

Keep track of all medications you are prescribed while in the hospital.

hen you get home add all other medications—including over-the-counter,

vitamins and herbs—to this list. Update your list as needed.

Medications received in the hospital and/or prior to admission may be differ-

ent on the day of discharge. Patients should follow the final treatment plan with

all current, up-to-date medications, dosages, and administration times.

Medication:

_____________________________________________________________

(include brand and generic names)

Dose: Take _______ times per day at (circle all that apply): 12–1 a.m. / 2–3 a.m. / 4–5 a.m. / 6–7 a.m.

8–9 a.m. / 10–11 a.m. / 12–1 p.m. / 2–3 p.m. / 4–5 p.m. / 6–7 p.m. / 8–9 p.m. / 10–11 p.m.

Reason for taking: _________________________________________________________

Prescribed by: _____________________________ Date started:_____________________

Pharmacy name and number: ___________________________ /_____________________

Medication:

_____________________________________________________________

(include brand and generic names)

Dose: Take _______ times per day at (circle all that apply): 12–1 a.m. / 2–3 a.m. / 4–5 a.m. / 6–7 a.m.

8–9 a.m. / 10–11 a.m. / 12–1 p.m. / 2–3 p.m. / 4–5 p.m. / 6–7 p.m. / 8–9 p.m. / 10–11 p.m.

Reason for taking: _________________________________________________________

Prescribed by: _____________________________ Date started:_____________________

Pharmacy name and number: ___________________________ /_____________________

Medication:

_____________________________________________________________

(include brand and generic names)

Dose: Take _______ times per day at (circle all that apply): 12–1 a.m. / 2–3 a.m. / 4–5 a.m. / 6–7 a.m.

8–9 a.m. / 10–11 a.m. / 12–1 p.m. / 2–3 p.m. / 4–5 p.m. / 6–7 p.m. / 8–9 p.m. / 10–11 p.m.

Reason for taking: _________________________________________________________

Prescribed by: _____________________________ Date started:_____________________

Pharmacy name and number: ___________________________ /_____________________

: 989-894-3000

ealthy Advice Patient Guide

My Medications List Template