List your prescription medicines to keep track of what you need to take, and show it to your doctor or pharmacist.
My name ___________________________________
Contact information ___________________________
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Prescription Medicines
Name and How Much Medicine | Color | What It Is For | Date Began Taking | How Much To Take and When | Do Not Take With |
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(example) Tetracycline 250 mg |
White | Respiratory infection | 2/8/2011 | 1 tablet 4 times a day 9 a.m., 1 p.m., 5 p.m., 9 p.m. |
Antacids or dairy products |
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Blood type: ________________________________
Medical conditions: __________________________
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Emergency Contact
Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________
Nonprescription medicines
___ Cold or cough medicines
___ Aspirin or other pain relievers
___ Allergy relief medicines
___ Antacids
___ Sleeping pills
___ Laxatives
___ Diet pills
___ Other: __________________________________________________________
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Medicines I should not take because of bad reactions or allergies: ________________
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Vitamins, herbals, and supplements
___ Vitamins (type): __________________________________________________
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___ Glucosamine chondroitin
___ St. John's wort
___ Ginkgo biloba
___ Ginseng
___ Other: __________________________________________________________
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