HTML Preview Printable Simple Medication List page number 1.
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MY MEDICATION LIST
Date Form Updated:________________
Name:
Primary Doctor: Phone:
Birth Date:
Other Doctor(s): Phone:
Phone Number:
Primary Pharmacy: Phone:
Emergency Contact
(name & phone):
Other Pharmacy(s) Phone:
List All Allergies (Medication or Food)
Allergic to: Describe reaction Allergic to: Describe reaction
List All Prescription Medications, Over-The-Counter Medicines, Herbal Supplements or Vitamins You Take
(continue on second page if needed)
Date
Started
Name of Medicine &
Strength (ex. mg, units…)
How to take (ex: take 1 tablet by mouth 2 times daily)
What time of day do you
take the medicine?
Why are you taking this
medicine? Or comments
Morning
Noon
Dinner
Bedtime
As
needed
Please keep this form updated. Bring it with you to medical appointments.
t at http://www.ucdmc.ucdavis.edu/pharmacy