Universal Medication Form

Universal Medication Form – Detailed Information

Keep this form as a record of your medicines. Always keep this form with you.

• Name:
• Address:
• Phone number:
• Birth date:
• Allergic to/describe reaction:

Instructions

• Take this form to all:
  • Health care provider visits.
  • Medical tests (lab, X-ray, MRI, CT scan).
  • Preassessment visits for admission or surgery.
  • Hospital visits (ER, inpatient admission, and outpatient visits).
• Update this form when changes are made to your medicines. Draw a line through any medicine that was stopped, and record the date when it was stopped. If you need help to fill out this form, ask your health care provider, nurse, or pharmacist.
• In the Commentssection, record the name of the health care provider who prescribed each medicine for you and the reason you take the medicine.
• When you are discharged from the hospital, an updated form will be given to you. Take the new form with you the next time you see your health care provider.

List of medicines (medications) and doses (dosages)

List all prescription and over-the-counter (nonprescription) medicines that you take on a regular basis. Include prescription medicines that you take as needed. Make copies of this blank form if you need more space to fill in your medicines.

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Name of medicine/dose:____________________________/______ Date prescribed:_____

Directions for taking this medicine:________________________________________________

Reason for taking:____________________________________________Date stopped: ______

Health care provider name:_______________________Comments:______________________

Immunization record

Record the most recent date when you received these vaccines:

• Tetanus:
• Pneumonia vaccine:
• Flu (influenza) vaccine:
• Hepatitis vaccine:

Basics of medication management

Understand your medicines

• Read all of the labels and the inserts that come with your medicines. Review the information on this form often. Ask your health care provider any questions that you have about prescription and nonprescription medicines that you take.
• Know the potential side effects for each medicine that you take.
• Talk with your pharmacist if you notice a difference in the size, color, or shape of your medicine or if you have trouble recognizing your different medicines.
• Get all of your medicines at one pharmacy. The pharmacist will have all of your information and understand possible drug interactions.

Take your medicines safely

• Take medicines only as directed by your health care provider.
• Tell your health care provider if you experience side effects, have new symptoms, or have other concerns.
• Review your medicines regularly with your health care provider. Ask if you need to continue to take each medicine, and discuss how well each one is working. Medicines, diet, medical conditions, weight changes, and other habits can all affect how medicines work.
• Do nottake a double dose of your medicine, unless told to do so by your health care provider.
• Do nottake anyone else’s medicine. Do notshare your medicine with other people.
• Do notstop taking your medicines unless you have talked about that with your health care provider.
• Do notsplit, mash, or chew medicines unless your health care provider tells you to do so. Tell your health care provider if you have trouble swallowing your medicines.
• For liquid medicines, make sure to use the dosing container that came with the medicine.
• You may need to avoid alcohol or certain foods or liquids with one or more of your medicines.

Organize your medicines

• Use a tool, such as a weekly pillbox, a written chart from your health care provider, a notebook, or your own calendar to organize your medicine schedule. Use that tool to help you remember information about each medicine, including:
  • Dose.
  • Schedule, including the day and time when it should be taken.
  • Appearance by size, shape, color, and stamp.
  • Requirements for taking with or without food or fluids.
• If you have trouble recognizing your different medicines, keep them in the original bottles.
• Create reminders for taking your medicines. Use sticky notes, or use alarms on your watch, mobile device, or phone calendar.
• Review your medicine schedule with a family member or a friend to help you. Other household members should understand your medicines.
• If you are taking medicines on an “as needed” basis, such as medicines for nausea or pain, write down the name, dose, and time each time you take it.

Plan ahead for refills and for travel

• Take your pillbox, medicines, and calendar system with you when you travel.
• Have your medicine refilled before you leave for travel. This will ensure that you do not run out of your medicines while you are away from home.
• Always take this form with you when you travel. If there is an emergency, a respondent can quickly see what medicines you are taking.

Store and discard your medicines safely

• Store medicines in a cool, dry area away from light or as directed by your pharmacist or health care provider. The bathroom is not a good place for medicine storage because of heat and humidity.
• Store your medicines away from chemicals, pet medicines, and medicines of other family members.
• Keep medicines where children cannot reach them. Store medicines up high in cabinets or on shelves.
• Check expiration dates regularly. Discard medicines that are older than the expiration date.
• Learn about the best way to dispose of each medicine that you take. Find out if your local government recycling program, hospital, or pharmacy has a medicine take-back program for safe disposal. If not, some medicines may be mixed with inedible substances and thrown away in the trash.

Pediatric considerations

If you are taking care of an infant or child who needs multiple medicines, follow the tips to organize a medicine schedule and safely give and store medicines.

• Use positive reinforcement for your child to help him or her take necessary medicines. Try singing, cuddling, and rewards.
• Use only the syringes, droppers, dosing spoons, or cups from your health care provider or pharmacist.
• Always wash your hands before giving medicines.
• Learn about medicine policies at your child’s school. Meet with the school nurse to review the medicine schedule in detail. Never send the medicine to school with your child.
• If your child has trouble taking medicine, forgets a dose, or spits it up, talk with his or her health care provider.
• Make sure that your child knows how to use an inhaler properly, if needed.
• Do notgive over-the-counter cough and cold medicines to your child who is under 2 years of age, unless directed by your health care provider.
• Do notgive your child aspirin or aspirin-containing products because of the association with Reye syndrome.