advertisement

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)

 



 

APA Reference
Gluck, S. (2007, February 7). Medicine Record Form, HealthyPlace. Retrieved on 2019, June 27 from https://www.healthyplace.com/depression/antidepressants/medicine-record-form

Last Updated: May 18, 2019

Medically reviewed by Harry Croft, MD

advertisement