Medicine Record Form

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This form can help you keep track of your medicines, vitamins, and other dietary supplements. You can make copies of the blank form and use it again. Take this with you each time you go to the doctor or pharmacist.

Select to download the print version (PDF File, 38 KB). PDF Help.

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Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________

Blood type: ________________________________

Medical conditions: __________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Emergency Contact

Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________

Nonprescription medicines

___ Cold or cough medicine
___ Aspirin or other pain reliever
___ Allergy relief medicine
___ Antacids
___ Sleeping pills
___ Laxatives
___ Diet pills
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________

Medicines I should not take because of bad reactions or allergies: ________________
___________________________________________________________________
___________________________________________________________________

Vitamins, herbals, and supplements

___ Vitamins (type): __________________________________________________
___________________________________________________________________
___________________________________________________________________

___ Glucosamine chondroitin
___ St. John's Wort
___ Ginkgo biloba
___ Ginseng
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________

Prescription Medicines

Name and Strength of Medicine	Color	What It Is For	Date Began Taking	How Much To Take and When	Do Not Take With
(example) Tetracycline 250 mg	White	Respiratory infection	2/8/2003	1 tablet 4 times a day 9 a.m., 1 p.m., 5 p.m., 9 p.m.	Antacids or dairy products

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