Medication Record .pdf

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Original filename: Medication Record.pdf
Author: Dave Winters

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My Personal Medication Record – Keep it Handy
• List all prescriptions, over-the-counter drugs, vitamins and herbs.
• Bring this to every doctor’s appointment and if you go to the emergency room or hospital. Date:________________________

Name and Dose of
Medication

This Medicine
is for my

How Much and How Often?
Morning

Noon

Evening

Notes/Questions

Bedtime

____________

Example:

Example:

Example:

Simvastatin 40 mg

High cholesterol

1 pill

Example: Ordered by
Dr. Brown / After I brush my teeth

If you have any problems with your medicine – do not wait. Talk to your doctor right away.
Patient Name:_ _____________________________________________ Allergies_________________________________________________
Doctor Phone Number:______________________________________________
Pharmacy Name & Phone Number:_ __________________________________________________

How Much and How Often?
Name and Dose of
Medication

This Medicine is
for my

Morning

Noon

Evening

Notes/Questions

Bedtime

____________
Example:
Simvastatin 40 mg

Example:
High cholesterol

Example:
1 pill

Example: Ordered by Dr.
Brown / After I brush my teeth


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