Premera My Medication List printable pdf download

Premera My Medication List

Physicians and providers: Review this list and

My medication list

instruct the patient on any changes you make.

Name _______________________________________________________________________________________

Physician Name ___________________________________________ Phone ____________________________

Here’s how to find out if your particular combination of medications are safe:

1. List all your medications below, including over-the-counter medicines, vitamins and

herbal supplements.

2. Review your medication list once a year with your healthcare provider.

3. Ask your doctor to explain each medicine:

• Why you are taking it

• How long you can expect to take it

• Describe any possible side effects.

Name of Medicine

Dose

Directions for use

Why taking it?

Example:

0.05 mg

Once daily for 90 days.

thyroid

Synthroid

Provided by Premera Blue Cross and Premera Blue Cross Blue Shield of Alaska, an Independent Licensee of the Blue Cross Blue Shield Association.

012998 (11-2008)

Premera My Medication List