A weekly prescription drug
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WEEKLY PRESCRIPTION DRUG REGIMEN Your Name: ____________________________ Drug: Dosage: For: Drug: Dosage: For: Drug: Dosage: For: Drug: Dosage: For: QUESTIONS TO ASK FOR EACH DRUG HOW MANY? WHEN SHOULD I TAKE? TAKE W/ FOOD? TAKE W/ WATER? AVOID: SUN MON TUES WED THUR HOW MANY? WHEN SHOULD I TAKE? TAKE W/ FOOD? TAKE W/ WATER? AVOID: HOW MANY? WHEN SHOULD I TAKE? TAKE W/ FOOD? TAKE W/ WATER? AVOID: HOW MANY? WHEN SHOULD I TAKE? TAKE W/ FOOD? TAKE W/ WATER? AVOID: Last updated: ____________________ Prescribed by: (Doctor’s name) PHONE: (Doctor’s phone number) FRI SAT WEEKLY PRESCRIPTION DRUG REGIMEN EXAMPLE Your Name: Jane Doe MOBIC * Dosage: 7.5mg Drug: For: arthritis SUN MON TUES WED THUR FRI SAT ONE ONE ONE ONE ONE ONE ONE every morning every morning every morning every morning every morning every morning every morning TOPROL * Dosage: 5mg Drug: For: hypertension/high blood pressure WAFRIN * Dosage: 5mg Drug: For: thinning blood/stroke prevention LANOXIN * Dosage: .25mg Drug: For: heart arrythma TORSEMIDE * Dosage: .20mg Drug: For: water build-up/ diuretic CYMBALTA * Dosage: 30mg Drug: For: neuropathy in feet Last updated: July 15, 2006 ½ ½ ½ in the morning in the morning in the morning ½ ½ ½ in the evening in the evening in the evening ½ ONE ½ ONE ½ ONE ½ in the morning in the morning in the morning in the morning in the morning in the morning in the morning ONE ONE ONE ONE ONE ONE ONE every evening every evening every evening every evening every evening every evening every evening ½ ½ ½ ½ ½ ½ ½ every morning every morning every morning every morning every morning every morning every morning ONE ONE ONE ONE ONE ONE ONE at bedtime at bedtime at bedtime at bedtime at bedtime at bedtime at bedtime * Prescribed by: Dr. John Doe PHONE: (000) 555-1212 NOTES: Avoid grapefruit and grapefruit juice.
