drmowdds.com - My Medication Record

My Personal Medication Record
My Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
Primary Care Physician
Name
Phone Number
Please enter a valid phone number.
Pharmacy/Drugstore
Pharmacist
Phone Number
Please enter a valid phone number.
Other Physicians
How to Use This Guide
- Save this document to your PC and email it to our office at
- Edit the copy on your PC to keep track of your medications (including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins.)
- Share the information with your doctors and pharmacists at all visits.
- Keep a printed copy always with you.
You should review this record when
- Starting or stopping a new medicine.
- Changing a dose.
- Visiting your doctor
Last Updated:

MonthDayYear
Date
My Allergies
My Medical Conditions

* Be sure to include ALL prescription drugs over-the-counter drugs, vitamins, and herbal supplements.

	What I’m taking	Form (pill, injection, liquid, patch, etc.)	Dosage	How Much and When	Use (regularly or occasionally)	Start/Stop Dates (1/5/05 - 3/5/05) (1/5/05 - ongoing)	Notes, Directions, Reasons for Use
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Should be Empty: