Please print the forms below, complete them, and carry with you at all times

Personal Medication Record

Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.

Name: ___________________________ Date of Birth: _________________

Medicine Name Include: Prescription, Over-the-counter, Herbals, Supplements	Medicine Strength How much do I take?	How do I use it? When do I use it?	Why am I using it?	Who told me to use it? How do I contact them?

Personal Medication Record

Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.

Name: _________________________ Date of Birth: _________________

Emergency Contact Information
Name
Relationship
Number
Primary Care Doctor
Name
Phone Number
Additional Doctors
Name(s)
Phone Number(s)

Allergies
What allergies do I have? (Medicines,food, other)	What happened when I had the allergy or reaction?





Other medicine problems
Name of medicine that caused problem	What was the problem I had with the medicine?




Questions I have about my medicines
Name of medicine I have a question about	What questions do I have for my doctor, pharmacist, or other health care provider?