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My Medication Record
My Medication Record
Name: 
Birth date: 
Include all of your medications on this record: prescription medications, nonprescription medications, herbal products, and other dietary supplements.
Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.
Drug Take
for
When do I take it? Start
Date
Stop
Date
Doctor Special
Instructions
Name Dose Morning Noon Evening Bedtime

This sample Personal Medical Record (PMR) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of the PMR or the information therein. If he or she does so, the he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the PMR is not a substitute for obtaining professional healthcare advice or treatment. This PMR may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded within.

 
My Medication Record
Name: 
Birth date: 
Phone: 
Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers.
Emergency Contact Information
Name
Relationship
Phone Number
Primary Care Physician
Name
Phone Number
Pharmacy/Pharmacist
Name
Phone Number
Allergies
What allergies do I have? (Medicines, food, other)
What happened when I had the allergy or reaction?
Other Medicine Problems
Name of medicine that caused problem
What was the problem I had with the medicine?
When you are prescribed a new drug, ask your doctor or pharmacist:
  • What am I taking?
  • What is it for?
  • When do I take it?
  • Are there any side effects?
  • Are there any special instructions?
  • What if I miss a dose?
Notes:
Patient's Signature
Healthcare Provider's Signature
Date last updated
Date last reviewed by  
healthcare provider