Make your own free website on
Daryl's WLS Bulletin
Medication List


Mission Statement
Contact Me
Who's Who?
Gallery of Photos
At the Doctor's Office
On the Table
In the Garden
Advertiser's Page

Enter subhead content here

Personal Medication Record

medications you               medications you                       medications you have

take every day:                  you take periodically:              taken in the past:

--------------------------         ------------------------------           ------------------------------

Medication Name             Medication Name                     Medication Name

--------------------------          -----------------------------              ----------------------------

Rx / Non-Rx                        Rx / Non-Rx                                Rx / Non-Rx

date & doctor                    date & doctor                             date & doctor

--------------------------         ----------------------------                 -----------------------------

Dosage                                Dosage                                         Dosage

---------------------------         ---------------------------                   ----------------------------

Purpose                               Purpose                                       Purpose

---------------------------          --------------------------                  -----------------------------

How Taken                         How Taken                                  How Taken

(with / without food)         (with / without food)                (with / without food)

---------------------------         -----------------------------               ----------------------------

Any Side Effects?             Any Side Effects?                     Any Side Effects?

---------------------------         ---------------------------                 ----------------------------

Your Name & Phone Number 


Doctors Name & phone Number                                        Did it work?

-------------------------------------------------------------               -----------------------------

What Pharmacy filled Rx?


Take this list with you when you go to the doctor, so he can go over all Perscription and Non-Perscription medications you take. Be sure to list even the "Over the Counter" drugs and/or herbs you take!