Personal Medication Record
medications you medications you medications you have
take every day: you take periodically: taken in the past:
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Medication Name Medication Name Medication Name
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Rx / Non-Rx Rx / Non-Rx Rx / Non-Rx
date & doctor date & doctor date & doctor
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Dosage Dosage Dosage
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Purpose Purpose Purpose
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How Taken How Taken How Taken
(with / without food) (with / without food) (with / without food)
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Any Side Effects? Any Side Effects? Any Side Effects?
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Your Name & Phone Number
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Doctors Name & phone Number Did it work?
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What Pharmacy filled Rx?
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