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Universal Medication Form


Use our Universal Medication Form to stay safe and healthy.  This form helps you and your family members remember all of the medicines you are taking by providing your doctor(s) and others with a current list of ALL of your medicines. Doctors need to know the herbals, vitamins, and over-the-counter medicines you take! 

Steps to Follow

  1. ALWAYS KEEP THIS FORM WITH YOU. You may want to fold it and keep it in your wallet along with your driver’s license. Then it will be available in case of an emergency.
  2. Write down all of the medicines you are taking and list all of your drug allergies. 
  3. Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
  4. WRITE DOWN ALL CHANGES MADE TO YOUR MEDICINES on this form. If you stop taking a certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask your Doctor, Nurse, Pharmacist, or family member to help you to keep it up-to-date.
  5. Write down the name of the doctor who told you to take the medicine(s). You may also write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).
  6. When you are discharged from the hospital, someone will talk with you about WHICH MEDICINES TO TAKE AND WHICH MEDICINES TO STOP TAKING. Since many changes are often made after a hospital stay, a new form should be filled out. When you return to your doctor, take your new form with you. This will keep everyone up-to-date.