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My Medicine Record
Use this record to keep track of your prescription medicines, over-the-counter medicines and dietary supplements.
You can store the record on your personal computer. Keep a printed copy with you at all times; share the record with your doctors, pharmacists, or other health professionals at all visits.
My Medicine Record is available in two formats — Adobe Acrobat and Microsoft Word:
- Adobe Acrobat - The Medicine Chart and Personal Information Sheet can be printed and filled in by hand with a pencil or are fillable on your computer. Saving and/or retrieving your data can only be done using the full version of Adobe Acrobat or Adobe Approval, not with the free Adobe Acrobat Reader.
- Microsoft Word - The Medicine Chart and Personal Information Sheet can be printed and filled in by hand with a pencil or are fillable on your computer. There are no restrictions on saving and editing your information.
You can print or download the entire "My Medicine Record" at once — its four pages include a chart for your medicines, space for personal information and instructions — or you can print or download "My Medicine Record" in parts.
The FDA video "Helping Patients Keep Track of their Medicines" provides an overview of My Medicine Record's usefulness.
- My Medicine Record -- Instructions
- Instructions to assist you with filling out "My Medicine Record"
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- My Medicine Record -- All Pages
- Medicine Chart
- Personal Information Sheet
- Instructions
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- My Medicine Record -- Medicine Chart
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- My Medicine Record -- Extra Medicine Chart
- Unnumbered medicine chart; use to add to your original medicine chart
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- My Medicine Record -- Personal Information Sheet
- Use this page to help you remember the questions to ask your health care professionals and the information that you need for filling in medical forms. Record your pharmacy number, emergency contact, and more.
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Date created: October 6, 2006; updated October 16, 2007 |
