Print this page and fill it in with your medication containers or current records beside you. Include nonprescription medicines and supplements. Ask your clinician or pharmacist to check unclear or conflicting instructions.
Your current medicines
Name: _________________________________ Updated: _______________
Allergies and reactions: ____________________________________________________
Pharmacy / phone: ________________________________________________________
| Medicine / strength | Dose / route | When / how often | Purpose, prescriber, or question |
|---|---|---|---|
Questions or differences to check:
________________________________________________________________________
________________________________________________________________________
This sheet organizes information. It does not prescribe or change treatment. Do not guess a missing direction. Follow your prescribing clinician’s instructions.