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Medication Reconciliation Form Template

Streamline Your Patient's Medication Information Easily

Struggling to keep track of your patient's medications can lead to serious health risks. This medication reconciliation form template is designed for healthcare professionals who want to ensure accurate medication records and enhance patient safety. By using this template, you can effectively track prescriptions, prevent medication errors, and streamline the review process, all while complying with WCAG-aligned accessibility standards. Experience a more organized approach to patient care-try our live template now.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Phone number
Email address
Home address (street, city, state, ZIP)
Preferred language
English
Spanish
Chinese
French
Prefer not to say
Other
Please Specify:
Emergency contact name
Emergency contact phone
Primary care provider name
Primary care provider phone
Preferred pharmacy name
Preferred pharmacy phone
Relationship to you
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Caregiver
Other
Please Specify:
List all allergies and reactions (medications, foods, latex, etc.), or enter None
Current medical conditions or diagnoses
Do you currently take any medications, vitamins, herbals, or supplements?
Yes
No
List all items you take. Include name, strength, route, dose, frequency, reason, prescriber, and last dose date
Have you experienced any medication side effects recently?
None
Nausea
Dizziness
Headache
Rash/Hives
Stomach upset
Fatigue
Sleep problems
Other
Please Specify:
In the past 7 days, how often did you miss a dose?
Never
Rarely
Sometimes
Often
Always
What makes it hard to take your medications?
Please Specify:
Briefly describe recent medication changes (name and what changed)
Since your last visit, have there been any medication changes?
No changes
Started a new medication
Stopped a medication
Dose changed
Formulation changed
Not sure
Have you had a hospital, ER, or urgent care visit in the past 30 days?
Yes
No
If yes, provide details including dates, facility, and treatments
Are you pregnant or breastfeeding?
Not applicable
Currently pregnant
Planning pregnancy
Breastfeeding
Prefer not to say
I confirm the information provided is accurate to the best of my knowledge
Yes
No
Signature
Date signed
I allow you to contact my providers and pharmacy to obtain or update my medication list
Yes
No
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Paper art illustration depicting a medication reconciliation form template for FormCreatorAI article.

When to use this form

Use this form at admission, transfer, discharge, or any visit where you start, stop, or adjust meds. It is valuable in the ED, pre-op, primary care, and home health. Ask patients or caregivers to list prescriptions, OTCs, vitamins, and herbals; confirm doses, routes, and timing; and capture who manages the meds. The result is a clean, current list you can order from and share with the care team. If you will administer doses soon after intake, pair it with the Medication administration form. When you uncover duplicates, interactions, or wrong doses, document and follow up using the Medication error report form.

Must Ask Medication Reconciliation Questions

  1. What prescription medications do you take, including dose, route, frequency, and why you take each one?

    This gives you a complete list to reconcile against the chart and pharmacy records. Clear details prevent wrong drug, dose, or route errors during ordering.

  2. Do you use any over-the-counter medicines, vitamins, or herbal supplements?

    Many interactions and side effects come from nonprescription products. Capturing them helps you avoid duplications and harmful combinations.

  3. Have any medications changed in the last 30 days, and who made the change?

    Recent changes often explain symptoms, adherence issues, or confusion. It also supports clear handoffs when you summarize with the SBAR Form.

  4. Do you have any drug allergies or past adverse reactions? What happened and when?

    Knowing the reaction, not just the label allergy, guides safe alternatives. It reduces the risk of repeating a prior adverse event.

  5. How do you take your medications at home, and do you ever miss or skip doses?

    Understanding real-world use reveals adherence gaps and barriers. You can tailor instructions, packaging, or timing to improve safety.

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