Medicine Wallet Card
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My name ___________________________________
Contact information ___________________________
___________________________________________
___________________________________________
Prescription Medicines
Name and How Much 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 |
2/8/2011 |
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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Blood type: ________________________________
Medical conditions: __________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Emergency Contact
Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________
Nonprescription medicines
___ Cold or cough medicines
___ Aspirin or other pain relievers
___ Allergy relief medicines
___ 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: __________________________________________________________
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