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Medications
Date & Reason Taken
Dose & When Taken
Time(s)
Example: Amoxicillin 250mg
5/12/16 Bladder Infection
1 capsule 3 times a day
9 a.m., 12 p.m., 6 p.m.
What are you allergic to?
List all meds, suppliments or foods
List all meds, suppliments or foods.
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Use this handy reference guide! Write the name of each medication you take, why you take it and when. Add new medications as they are prescribed and mark o medications if they have been discontinued. Carry this handy reference with you to appointments and hospitalizations. Keep your list updated, ask your healthcare professional(s) to assist you.
o Cold & Flu o Allergy
o Nasal Spray o Aspirin
o Ibuprofen (Advil)
o Tylenol o Vitamins o Diet Pills o Antacid
o Sleep Aid
o Laxative
o Nausea/Diarrhea o Other
Describe symptoms
Your Physicians
Physician:
Phone: Specialty:
Physician:
Phone: Specialty:
Over-The-Counter Medications
This is your chance to ask your
Doctor any questions about your medications. DON’T BE SHY, ASK THEM WHY!
MEDICINE MINDER