When seeing a new physician or going to the hospital for a procedure, you often have lots of questions and many things to think about. Keeping track of which medications you are taking, including the drug name, dosage and frequency, is an important part of staying healthy. Remember to include any natural supplements, herbs, vitamins and over-thecounter agents you are taking.

The form below is a good thing to have on hand for yourself and each family member. Complete all of the fields and then take it with you whenever you see a doctor or other health care provider.

This simple form can help you use medicine safely. Keep it current, and take it with you to each hospital or doctor's visit.

Print and cut out for your records.

MY MEDICATION RECORD Name: __________________________________Birth date: ____ /____ /____ Allergies: _______________________________________________________
Medication name	What is it for?	Dose	How often?	Prescribed by: (Phone #)
Example: Aspirin	Headache	200 mg	Once per day	Dr. John Doe, (123) 456-7890

INTEGRIS Health 3300 N.W. Expressway, Oklahoma City, OK 73112 (405) 949-3011 | HealthLine: (888) 951-2277