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For a number of reasons it's wise to keep an up-to-date record of all medications you, or someone you care for, is taking. This form allows you to more easily keep track of these medications, providing a structured, printable record that you can save to your computer for later editing. Let's begin!

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Date filled:

Date updated:

Patient’s Date of Birth:

Drug Allergies:

Food Allergies:

	Name	Address	Telephone Number	E-mail address
Patient
Caregiver
Primary Care Physician
Primary Pharmacy

Here are some questions that the caregiver can ask the health care provider about the medicine:

Note: Ask the doctor or pharmacist to review the personal medication record form at each encounter and make sure it is accurate

What is the medication for?
Do any of the current medications need to be stopped when the new medicine is started?
How should this medication be taken? (Specifically ask if the medication needs to be slowly increased and how)
Are there any tests that need to be done while on the medication?
How long this medication should be taken for?
How can I tell if the medication is working? When should I expect it to start working? (Ex: immediate affect or will take weeks)
What are the side effects and what should be done?
What if a dose is missed?
Can you give me printed information about this medication?

Prescription Medication and Prescriber	What is it for?	Strength	What does it look like? (form, color, shape, imprint, number)	How much, how often, and when do you take it?	How well is the medication working?	Start date / Stop date

Over The Counter Medication	What is it for?	Strength	How much, how often, and when do you take it?	How well does the medication work?

Vitamins and Herbal Supplements	What is it for?	Strength	How much, how often, and when do you take it?	How well does the medication work?

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» Please complete the following form.

Here are some questions that the caregiver can ask the health care provider about the medicine:

» Click [Continue]. You will print and save the next page for your records.