Medication Record

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Write down the name of each medication you take, the reason you take it, how you take it, and the form (tablet, capsule, liquid), color and shape of the medication. In the last column, write down side effects and any special instructions your doctor or pharmacist have told you about. List all prescription medications and all over-the counter medicines, including vitamins or other nutritional supplements, pain relievers, antacids, laxatives, and herbal remedies. Add new medicines when you start taking them.

Carry this list with you at all times in your purse or wallet. Show this form to your doctors whenever you have an appointment. Bring this form with you to your pharmacy when you get a prescription filled. You may want to make copies of the blank form so you can use it again.

Your Name and Address:
Your Primary Doctor:		Primary Doctor's Phone Number:
Other Doctor:		Other Doctor's Phone Number:
Your Pharmacy:		Pharmacy's Phone Number:
Your Health Problems:
Your Drug Allergies:

Name of Medication	Purpose or Reason Taken	Dose	Time(s) of Day	Form, Color, and Shape	Side Effects or Special Instructions
Example: Vasotec 5 mg.	To treat my high blood pressure	One tablet twice a day	7 a.m. 7 p.m.	white, round tablet	May cause dizziness during the first days of therapy.

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Always seek the advice of your pharmacist and/or physician before making any changes to your medication regimen. The senior care pharmacists described on this Web site are not endorsed by, or qualified by, the American Society of Consultant Pharmacists or its Research and Education Foundation. Patients, caregivers, professionals, and others using this website should conduct interviews, consult references, and take other appropriate measures to assess the qualifications of senior care pharmacists. The American Society of Consultant Pharmacists and its Research and Education Foundation disclaim any liability in connection with services rendered by a senior care pharmacist described on this Web site.