Medication Record

Prescription: __________________________________________

Current Date: ______________________________________________

Patient Information

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:_______________________________

Medication Specifics

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):

_______________________________________________

Dosage Information

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: ______________________

_______________________________________________

Warnings and Precautions

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.):

__________________________________________________

Other Key Information (allergies, medical conditions, emergency contact, etc.)

____________________________________________________________

Medication Record

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