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Medicine Record Form
For Keeping Track of Medications
Print this form. Write down the name of each medicine you take, the reason you take it, and how you take it, in the spaces below. Add new medicines when you get them. You can show the list to your health professionals. You may want to make copies of the blank form so you can use it again. This form was developed by the National Council on Patient Information and Education.
|
Name of medicine
|
Reason taken
|
Dosage
|
Time(s) of day
|
Over - the - Counter Medicines
(Check here if you use any of these)
 Laxatives |
| Dietary Supplements / Herbals |
| Vitamins |
| Cold medicine |
| Aspirin/other pain,headache, or fever
medicine |
| Cough medicine |
| Allergy relief medicine |
| Antacids |
| Sleeping pills |
| Others (names) |
|
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