Medicine List Examples
Tips:
- If printing, print the two-page documents to a single page, front-to-back.
- Save Word version files to your personal computer to be typed into and saved for later updates.
"Patients need to appreciate that they have a role in their health care."
--John Zarek, Director of Clinical Pharmacy for Swedish Medical Center, and a member of the Washington Patient Safety Coalition
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Medication List
From American Association for Retired Persons
This document is two full color pages. The first page includes directions, personal information and general medical information. The second page includes a simple table to be filled in with list of medicines.
PDF version, Word version
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My Medicine List
From American Society of Health Systems Pharmacists
This document is two full color pages. The first page includes directions with examples, personal information and general medical information. The second page includes a fairly detailed table organized by times of day that medicines are used.
PDF version
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Personal Medication Record
From South Carolina Hospital Association
This document is two full black and white pages. The first page includes personal information, general medical information and a simple table organized by date that medicines were started. The second page includes directions about how to fill out the table.
PDF version, Word version
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Personal Medication Record (Spanish)
Expediente Personal de Medicamentos
De La Asociación de Hospitales de Carolina del Sur
Este documento consiste de dos páginas.
La primera página incluye información personal e información general médica junto con una simple tabla que organiza la fecha de cuando las medicinas fueron comenzadas.
La segunda página incluye instrucciones en como llenar la tabla.
PDF version, Word version
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Speak Up™ My Medicine List
From the Joint Commission
This document is two full color pages. The first page includes a simple table organized by category of medicine. This table includes space for alcohol and recreational drugs. The second page includes directions with personal information and general medical information. This document can be trifolded to fit into a wallet.
PDF version
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My Medication List
From Harney District Hospital
This document is two full color pages. The first page includes minimal directions with personal information and general medical information. The list of medicines starts on the first page and continues to the second page. The list is not organized into a table form. This PDF version allows data to be entered in and printed but not saved.
PDF version
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My Medication Record
From the National Association of Chain Drug Stores Foundation and American Pharmacists Association
This document is two full black and white pages. The first page includes a fairly detailed table with no specific organization. The second page includes personal information, general medical information and a recommended list of questions to ask health care providers.
PDF version
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Pill Box
From Indiana Community Health Network
This free application for your iPhone or iPod Touch allows you to manage and reference information about your medicines through an informative database. The database can link to your schedule and contacts. You can also keep separate lists for each of your family members or dependents.
Link to download
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