Medication Record

Current Date: ______________________________________________

Name: _____________________________________________

Condition being treated: ________________________________

List of all prescription drugs being taken:

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

List of over-the-counter drugs being taken:

• pain relievers: ____________________________________

• sleep and motion-sickness aids:______________________

• headache remedies:_______________________________

• cold remedies: ___________________________________

• laxatives and upset stomach aids:_____________________

• herbal and vitamin supplements:

   _________________________________________________

   _________________________________________________

   _________________________________________________

Primary physician

• Name:__________________________________________

• Phone number:____________________________________

Pharmacy phone number:_______________________________

This prescription

•    Trade name:____________________________________

•    Generic/chemical name: ___________________________

Doctor prescribing

•    Name: ________________________________________

•    Phone number: __________________________________

Date prescribed: _____________________________________

Reason for prescribing

•   Why you need it: _________________________________

          ______________________________________________

•   How it will make you feel: ___________________________

        _______________________________________________

•   How you will know it's working: _______________________

         _______________________________________________

Possible side effects

•   Expected side effects: _____________________________

•   Problematic side effects (if occur, call doctor):

          ______________________________________________

•   Duration of use (week, month, indefinite): 

         _______________________________________________

Medication strength: ___________________________________

Medication dosage:

•   When and how often to take medication:

         _______________________________________________

•   Proper dose each time (2 pills, 3 ounces, etc.):

        _______________________________________________

•   How to take (empty stomach, with water, meal, etc.) 

         _______________________________________________

•   What to do if a dose is missed: ______________________

         _______________________________________________

Potential food/drug interactions (Be doubly safe: check with pharmacist and on-line rx)

   Foods/drinks to avoid (alcohol, caffeine, grapefruit, milk?)

   __________________________________________________

  Over-the-counter drugs to avoid (from above list):

   __________________________________________________

   __________________________________________________

  General Precautions (no driving, operating heavy machinery, etc.):

  __________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________