Medication Log

Name:________________________________Date:____________ Birth Date:______________

Prescribed Medications

Strength

Directions

Reason for taking

Prescribing Doctor

Metoprolol Succinate

25 mg

1 every morning

High blood pressure

Dr. Doe

Example:

Over The Counter

Strength

Directions

Reason for taking

Medications & Vitamins

Fish Oil

400mg

3 times a day

Cholesterol

Example:

Herbal Supplements

Strength

Directions

Reason for taking

Ginkgo Biloba

60 mg

Twice daily

Memory

Example:

Type of Adverse Reactions

Drug Allergies

PLEASE BRING THIS MEDICATION LOG WITH YOU TO YOUR NEXT OFFICE VISIT

If you run out of room please use the back of this form to list any additional medications

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Parent category: Medical