Personal Medication List Template - Cigna
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This medication list may help you keep track of your medications and how to use
them the right way.
Instructions:
Use this blank form to add prescription medications, over the counter drugs,
herbal products, vitamins, and minerals.
Cross out medications when you no longer use them. Then write the date
and why you stopped using them.
Ask your doctors, pharmacists, and other healthcare providers to update this
list at every visit.
If you go to the hospital or emergency room, take this list with you. Share
this with your family or caregivers too.
Allergies or side effects:
Medication:
How I use it:
Why I use it:
Prescriber:
Notes:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
Medication:
How I use it:
Why I use it:
Prescriber:
Notes:
Date I started using it:
Date I stopped using it:
Why I stopped using it:
If you have any questions about your medication list, call your physician,
pharmacist, or medication therapy management provider at 1-800-625-9432.
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