 Personal Medication Record
A Personal
Medication Record is a comprehensive record of your medications
including prescription, non-prescription medications, herbal products
and other dietary supplements
Why do I need a personal medication
record?
- To assist you in keeping track and managing all of your
medications
- To share with all of your health care providers, so they know about
all medication products you are taking
- To keep track of allergies and other problems that you have had with
medications in the past to avoid future problems
When should I start keeping a personal medication
record?
How do I use a personal medication record?
- Use a preprinted form that has all of the required types of
information you will need. If you don’t have a form, print
one out and get started.
- Fully complete the form legibly and accurately
- Keep your personal medication record up to date by making changes
every time you have a change of medication or any other personal
information changes
- Carry your personal medication record with you and actively share it
with all of your health care providers
- If you have questions, concerns or need help with your personal
medication list, ask your pharmacist or physician to assist you
Print
out a Personal Medication Record form to complete by hand.
What information should I include on my
record?
Your Personal Medication Record should include the following personal
information:
- Your name
- Your birth date
- Your phone number
- Emergency contact information (Name, relationship, phone
number)
- Primary care physician (Name and phone number)
- Pharmacy/pharmacist (Name and phone number)
- Allergies (e.g., What allergies do I have? What happened when I had
the allergy or reaction?)
- Other medication-related problems (e.g., What medication caused the
problem? What was the problem I had?)
- Potential questions for patients to ask about their medications
(e.g., When you are prescribed a new drug, ask your doctor or
pharmacist...)
- Date last updated
- Date last reviewed by the pharmacist, physician, or other health
care professional
- Your signature
- Healthcare provider’s signature
For each medication, include the following:
- Medication (e.g., drug name and dose)
- Indication (e.g., Take for…)
- Instructions for use (e.g., When do I take it?)
- Start date
- Stop date
- Ordering prescriber/contact information (e.g., doctor)
- Special instructions
Do I need to keep track of my immunizations?
In addition to keeping track of medications, keeping a list of your
immunizations is very important as well. Make sure that you have a
current immunization record.
If you don’t have one, you can print one at the Centers for
Disease Control & Prevention using the following links:
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