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Date of this Form: |
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My Name: |
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My Address: |
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My Doctor’s Name: |
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My Doctor’s Address: |
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My Pharmacist’s Name: |
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My Pharmacist’s Address: |
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My Health Problems: |
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My Drug Allergies: |
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In the table on the next page, write down the name of each medication, the reason it’s taken, how it’s taken and the form (tablet, capsule, liquid, color, shape) of the medication. Then, write the side effects and any special instructions the doctor or pharmacist has told you about. List all prescription medications and all over-the-counter medicines, including vitamins or other nutritional supplements, pain relievers, antacids, laxatives, and herbal remedies. Make a copy of this list and carry the copy with you at all times in your purse or wallet. Show this form to doctors whenever you have an appointment. Bring this form with you to your pharmacy when you get a prescription filled. You may want to make copies of the blank form so you can use it again.
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Name of medication |
Purpose or reason taken |
Dose |
Time(s) of day |
Form, color and shape |
Side effects or special instructions |
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Example: Vasotec 5 mg. |
To treat high blood pressure |
One tablet twice (2x) a day |
7 a.m. 7 p.m. |
white, round tablet |
May cause dizziness during the first days of therapy. |
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Source: American Society of Consultant Pharmacists Research and Education Foundation, Alexandria, Virginia
[1] Note: This document is meant for the clients of The Law Offices of Jerold E. Rothkoff. Before acting on any information presented here, you are strongly urged to consult with an attorney who is competent in this area of the law.