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Medication List Form Template

Streamline Patient Medication Tracking with Our Template

Keeping track of multiple prescriptions can be overwhelming for both patients and healthcare providers. This medication list form template helps you securely document and manage your medication information effectively. With this tool, you can ensure organized tracking of medications, easily share medication details with healthcare professionals, maintain adherence to prescribed treatments, and keep your medical history updated. Plus, it's designed with WCAG-aligned labels for accessibility. Explore how this template can simplify your medication management now.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Email address
Phone number
Medication 1 name
Medication 1 strength (include units, e.g., 20 mg)
Medication 1 directions (e.g., 1 tablet twice daily)
Medication 2 name
Medication 2 strength (include units, e.g., 20 mg)
Medication 2 directions (e.g., 1 tablet twice daily)
Medication 3 name
Medication 3 strength (include units, e.g., 20 mg)
Medication 3 directions (e.g., 1 tablet twice daily)
Additional prescription medications (list name, strength, directions; or write None)
List any over-the-counter medicines, vitamins, or herbal products (name, strength, directions; or write None)
Medication allergies and reactions (or write None)
Other allergies (foods, latex, etc.) and reactions (or write None)
Past side effects or intolerances to medications (or write None)
Preferred pharmacy name
Pharmacy phone number
Primary prescriber or clinic for your medications
Any other medication notes or instructions for your care team
How often do you miss a dose?
Never
Rarely
Sometimes
Often
Always
Your name (type to sign)
Signature date
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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paper art illustration depicting a medication list form for an article on FormCreatorAI

When to use this form

Use this form when you need a clear, up-to-date list to share with doctors, caregivers, or emergency staff. It is ideal for adults who take several prescriptions, parents tracking a child's inhalers and antibiotics, and patients getting ready for surgery or a new provider visit. Bring it to urgent care, annual checkups, or telehealth, so you can answer dosing questions fast. If you work in a care home, align your entries with the MAR Form to keep daily administrations consistent. For ongoing history across visits, pair this with a Medication record form. The outcome: fewer errors, faster intake, and better treatment decisions.

Must Ask Medication List Questions

  1. What is the exact medication name, strength, and dosage form?

    Specifics prevent look-alike and sound-alike mix-ups and ensure the right product. Clinicians use this to verify orders and avoid dosing mistakes.

  2. How often do you take it, at what times, and by which route (oral, inhaled, injection)?

    Schedule and route change how a drug works and interacts. Clear timing supports adherence and safe transitions between settings.

  3. What condition is it for, and which clinician prescribed it?

    Indication and prescriber stop duplicate therapies and clarify necessity. It also directs questions to the right provider.

  4. When did you start it, and have there been any recent dose changes or stops?

    Start and stop dates highlight changes that may explain new symptoms. They help teams adjust therapy quickly.

  5. Do you have allergies, side effects, or any recent medication errors to report?

    Reactions and allergies guide substitutions and monitoring. If an error occurred, use the Medication error report form so issues get fixed and documented.

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