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Medication Log

Mon, Jun 22, 2009

Ask the DoctorMedicationLog

About Your Medications

* Keep a list of all medications and supplements you take.

* Tell your primary care physician (family doctor), behavioral healthcare professional, sleep doctor, and/or pharmacist about all the medicines you take including any over-the-counter medicines, as well as any drug allergies that you may have.

* Ask your pharmacist about side effects and what foods or liquids to avoid while taking medications.

* Read the label, including warnings. Make sure that you receive the medication that was prescribed for you and you know how to use it.

* If the medication looks different than you expected, ask the pharmacist about it.

Medication Information Log

* Use this log to record the medications that you are taking. If you have any concerns about them, then ask your doctor.* Bring this log with you when you go to the doctor.

 

 

DESCRIPTION

Medication #1

Medication #2

Medication #N

Medication Name

and Dosage

 

 

 

Name of the doctor who

Prescribed the medication

 

 

 

Date on the medication

bottle

 

 

 

Are you still taking this

medicine?

Yes ( )

No ( )

Yes ( )

No ( )

Yes ( )

No ( )

Are you having any

Trouble with this

medicine?

Yes ( )

No ( )

Yes ( )

No ( )

Yes ( )

No ( )

How many pills do you

take at one time?

 

 

 

How many times a day

do you take your

medicine?

 

 

 

Problems with the

medication

 

 

 

 

List below any questions you might have for your doctor:

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

4. ____________________________________________________________

Allergies_______________________________________________________

______________________________________________________________ 

 

Personal Information:

Your Name    __________________________________________________

Address         __________________________________________________

Phone Number ________________________________________________

Primary Care Physician Name_____________________________________

Physician’s Address_____________________________________________

Physician’s Phone Number________________________________________

Emergency Contact _____________________________________________

_____________________________________________________________

 

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