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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