Prescription Medications
Start
Date
Name of Medicine
1/1/05
Feel Better
Brand name
Generic name too if
available
Prescribed
By
Dr. Help
Dose
(mg,
units,
puffs,
drops)
5 mg
When Do You
Take It?
How many times
per day?
Morning and
night? After
meals?
2 times –
morning,
night
Purpose
Why do
you take
it?
ulcer
Important
Comments
Stop
Date
Monitoring
Required
Notes
Date reviewed; Date
Updated
(e.g. danger signs,
side effects, drugdrug, drug-food
interactions, stopped
taking*)
(e.g. lab test
every _____
weeks)
Makes me
dizzy
Blood
5/18/05 - Reviewed
test every by Dr. Help and
4 weeks
Changed Dose to
10 mg.
*Always refer to physician and pharmacist input and the detailed drug sheets provided with each medication for a complete list of potential side effects/danger signs/interactions.
USE PENCIL
Whenever you see a doctor, including your primary care physician and any specialists, review and update this medication list.
After any hospitalization, check with your doctor to review this medication list.
Insert Logo Here
Patient Medication Card Prototype
Insert organization logo here
Information about you
Questions to Ask My Doctor
Your name: _______________________________________________________
Address:__________________________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Birth Date:____________ Blood Type: _________ Weight:________ Height: _______
name
_______________________
phone
______________
Primary care doctor: _______________________
______________
Other physicians:
(specialists)
_______________________
_______________________
______________
_____________
Emergency Contact: _______________________
______________
Pharmacy:
Medical Conditions
asthma
cancer
heart disease
kidney disease
Vaccinations
diabetes
high blood pressure
other_________________
Over-the-Counter Medications
(date of last immunization)
Influenza:__________ Pneumococcal:__________
MMR:____________ Tetanus/diphtheria:__________
Discontinued Medications or Products
(check all that you use regularly)
 Allergy relief,
antihistamines
 Antacids
 Herbals, dietary
supplements
 Laxatives
 Aspirin/other pain,  Sleeping pills
headache, or fever
 Cold/cough
 Vitamins, minerals
medicines
 Diet pills
 Others (list below):
Medication, Food, Environmental
Discontinued Medications, Allergy, Side Effects, Reaction or
Intolerance Experienced (symptoms, severity, dates)
Developed by the Massachusetts Coalition for the Prevention of Medical Errors