Bring a current list to appointments and ask a pharmacist or clinician to check details you are unsure about. This worksheet does not recommend treatment or changes to medicines.
Print and keep: Use your browser’s Print command (Ctrl+P or Command+P), then print or save as PDF. Fill in the worksheet by hand. This page does not collect or save your information.
Name: ____________________________ Last updated: ________________
Allergies / known reactions: _________________________________________
Medicines, vitamins, and supplements
| Name and strength | Amount / when used | Reason / prescriber |
|---|---|---|
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
Include prescription and nonprescription items, supplements, and anything used only when needed. Copy instructions accurately and ask your care team about any uncertainty. Do not change medicines based on this worksheet.
Questions for my pharmacist or clinician
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
Useful details
Pharmacy and phone: ______________________________________________
Person helping keep the list current, if any: ___________________________
Further reading: FDA: keeping a medication list