This form can help you keep track of your medicines, vitamins, and other dietary supplements. You can make copies of the blank form and use it again. Take this with you each time you go to the doctor or pharmacist.
Select to download the print version (PDF File, 38 KB). PDF Help.
Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________
Blood type: ________________________________
Medical conditions: __________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Emergency Contact
Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________
Nonprescription medicines
___ Cold or cough medicine
___ Aspirin or other pain reliever
___ Allergy relief medicine
___ Antacids
___ Sleeping pills
___ Laxatives
___ Diet pills
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________
Medicines I should not take because of bad
reactions or allergies: ________________
___________________________________________________________________
___________________________________________________________________
Vitamins, herbals, and supplements
___ Vitamins (type): __________________________________________________
___________________________________________________________________
___________________________________________________________________
___ Glucosamine chondroitin
___ St. John's Wort
___ Ginkgo biloba
___ Ginseng
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________
Prescription Medicines
Name and Strength of Medicine | Color | What It Is For | Date Began Taking | How Much To Take and When | Do Not Take With |
---|---|---|---|---|---|
(example) Tetracycline 250 mg |
White | Respiratory infection | 2/8/2003 | 1 tablet 4 times a day 9 a.m., 1 p.m., 5 p.m., 9 p.m. |
Antacids or dairy products |
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