Universal Medication Form

How Does This Form Help You?

Reduces confusion and saves time. You do not have to remember all the medications you are taking, the form does this for you.
Improves communication. Provides doctors, health care providers and institutions with a current list of ALL of your medications. Lets the patient and/or family member know exactly what medications are to be taken and when.
Improves MEDICATION SAFETY. Medication interactions and duplications can be detected and corrected.

Patients - How to Use It

Always keep this form with you.
Take this form to ALL doctor visits and ALL medical testing (lab, x-ray, MRI, CT, etc). Take this form to ALL preassessment visits for admission or surgery and ALL hospital visits (ER, in-patient admission, out-patient visits).
Update this form as changes are made to your medications. If a medication is stopped, draw a line through it and record the date it was stopped. If help is needed ask Physician, Nurse or Pharmacist to help you fill out this form.
In the COMMENTS column, record things like the name of doctor who told you to take this medication. You may also add the reason for taking the medication (high blood pressure, high blood sugar, high cholesterol).
Tell your family, friends and neighbors about the benefits of using this form.
When you are discharged from the hospital, you will get an updated form. This will be reviewed with you and you will be given a copy. When you return to your doctor, take your updated form with you. This will keep everyone up-to-date on your medications.