Medication List
Keep your medication list up to date, so in case of a relapse, you can accurately report this information to your healthcare provider(s). Some medications could be causing new or worsened symptoms as a side effect, or they may possibly interfere with other treatments.
Pharmacy Name:_____________________________________________________
Address:___________________________________________________________
Phone Number:______________________________________________________
Insurance:_________________________________________________________
Policy Number:_____________________________________________________
Group Number:______________________________________________________
Insurance Contact Info:____________________________________________
Medication #1
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
Medication #2
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
Medication #3
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
Medication #4
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
Medication #5
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
Medication #6
Name:_________________________
Dose:__________________________
Frequency:_____________________
Notes: ________________________
and friends | Table of Contents | Next: What should you tell your doctor when you call?