Overview
List each medicine that you take. Be sure to include over-the-counter medicines, herbs, vitamins, and other natural health products.
Use this as a guide when you fill out the chart.
- Medicine names. Include both the brand name and the generic name for all prescription medicines, even those prescribed by another doctor.
- Doctor's name. Include the name of the doctor who prescribed the medicine. This is especially important if you see more than one doctor.
- Pharmacy. Include the name and phone number of the pharmacy where you buy the medicine. If you use more than one pharmacy to get your medicines, make sure the pharmacist at each store knows all the medicines you are taking. The pharmacist can then check for medicine interactions.
- Date started. This is the date you started taking the medicine. This is especially important if you have been taking a certain medicine for a long period of time.
- Reason to take. Include a short phrase that tells why you are taking the medicine.
- Dose (such as 2 mg, 5 mL, 1 tsp). The amount of medicine in each pill appears on the prescription label in milligrams (mg). This is called the dose, or strength. The label on liquids and shots lists the dose too. Put the amount of the medicine you take each time you take a dose. For example, if you take a 50 mg pill, you would put 50 mg in this space, not one pill. If you take two 25 mg pills at a time, you would also put 50 mg.
- When to take. Put how often during the day you need to take the medicine, such as 3 times a day.
- Side effects to look for. Ask your doctor or pharmacist for side effects you need to watch for while taking the medicine.
Keep this master list of medicines up to date. Review it with your doctor at each visit. At the bottom, list medicines that you're allergic to or that you've stopped for other reasons.
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Medicine name
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Doctor's name
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Pharmacy
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Date started
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Reason to take
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Dose
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When to take
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Side effects to look for
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Allergies to medicines
Use the chart below to list all medicines, both prescription and over-the-counter, that you are allergic to.
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Medicine name
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Type of reaction, such as a rash or breathing difficulties
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Credits
Current as of: September 25, 2023
