www.talkaboutrx.org Medicine Record 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.
Prescription medicines
|
Name
of medicine
|
Reason
taken
|
Dosage
|
Time(s)
of day
|
Over - the - Counter Medicines
(Check here if you use any of these)
Laxatives |
Cough medicine |
|
Dietary Supplements / Herbals |
Allergy relief medicine |
|
Vitamins |
Antacids |
|
Cold medicine |
Sleeping pills |
|
Aspirin/other pain,headache, or fever medicine |
Others (names)
|
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NCPIE Phone:
(301) 656-8565 NCPIE Fax: (301) 656-4464 |