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Universal Medication Form

Full size sheets - DOC format | RTF format | PDF format
(Fold this form and keep it in your wallet)
Date form started:
Name:
Address:
Phone Number: Birth Date:
Emergency Contact/Phone numbers:
IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)

TETANUS:

FLU VACCINE(S):

PNEUMONIA VACCINE:

HEPATITIS VACCINE:

OTHER:
Allergic To /Describe Reaction: Allergic To /Describe Reaction:
   
   
   


LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).

DATE NAME OF MEDICATION / DOSE DIRECTIONS:
Use patient friendly directions.
(Do not use medical abbreviations.)
DATE STOPPED Notes: Reason for taking / Doctor's Name
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

Refer to page 2 for directions, benefits of using the form, and how to get more copies.

UNIVERSAL MEDICATION FORM

  1. ALWAYS KEEP THIS FORM WITH YOU. You may want to fold it and keep it in your wallet along with your driver’s license. Then it will be available in case of an emergency.
  2. Write down all of the medicines you are taking and list all of your allergies.
  3. Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
  4. WRITE DOWN ALL CHANGES MADE TO YOUR MEDICINES on this form. If you stop taking a certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask your Pharmacist, Doctor, Nurse, or family member to help you to keep it up-to-date.
  5. In the NOTES column, write down the name of the doctor who told you to take the medicine(s). You may also write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).
  6. When you are discharged from the hospital, someone will talk with you about WHICH MEDICINES TO TAKE AND WHICH MEDICINES TO STOP TAKING. Since many changes are often made after a hospital stay, a new form should be filled out. When you return to your doctor, take your new form with you. This will keep everyone up-to-date on your medicines.

HOW DOES THIS FORM HELP YOU?

  1. This form helps you and your family members remember all of the medicines you are taking.
  2. Provides your doctor(s) and others with a current list of ALL of your medicines. Doctors need to know the herbals, vitamins, and over-the-counter medicines you take!
  3. Helps you – concerns may be found and prevented by knowing what medicines you are taking.
OSHP Logo
Oklahoma Society of Health-Society Pharmacists
P. O. Box 2371
Oklahoma City, OK 73101-2371
www.oshp.net
Last Updated on Wednesday, 11 June 2014 13:27
 
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