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Medication Record Form Template

Efficiently Manage Your Medication History with This Template

Struggling to keep track of your medications can lead to missed doses and confusion. This Medication Record Form Template is designed to help you manage your medication history effectively, ensuring that you and your healthcare providers have accurate information at hand. Benefit from streamlined tracking of prescription fills, a complete overview of your current medications, and easy access for caregivers, all while adhering to WCAG-aligned standards for accessibility. Start using the live template today to simplify your medication management.

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Full name
Date of birth
Phone number
Email address
Medication name
Medication form
Tablet
Capsule
Liquid
Injection
Inhaler
Patch
Ointment/Cream
Drops
Other
Please Specify:
Strength (e.g., 500 mg)
Dose per administration (e.g., 1 tablet)
Route of administration
Please Specify:
Intended use or condition
Start date
End date (if applicable)
Frequency
Once daily
Twice daily
Three times daily
Four times daily
Every other day
Weekly
Monthly
As needed (PRN)
Other
Please Specify:
Dose date
Dose time (HH:MM)
Dose taken as scheduled
Yes
No
Side effects or symptoms since last dose
Notes for this entry
If dose was missed, reason
Forgot
Ran out of medication
Side effects
Could not access medication
Following provider instruction
Not applicable
Other
Please Specify:
Do you have any drug allergies
Yes
No
List drug allergies and reactions (or write None)
Relevant medical conditions to consider
Pregnancy or breastfeeding status
Pregnant
Planning pregnancy
Breastfeeding
None of the above
Prefer not to say
Prescribing provider name
Prescribing provider phone
Pharmacy name
Pharmacy phone
Signature
Date
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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Colorful paper art illustration depicting a medication record form with medication lists and checkboxes

When to use this form

Use this form when you need a clear, up-to-date view of a person's medicines at home, in a clinic, or during a handoff. Bring it to a new patient intake, a post-surgery follow-up, or a caregiver change so everyone sees the same dose, schedule, and prescriber. Start with the Medication list form to capture every drug, then use this record to log changes, missed doses, and side effects. For daily administration in home health or a facility, copy key details into the MAR Form to guide safe dosing. In emergencies, having this record ready helps paramedics and ED staff make fast, safe decisions alongside the Ambulance patient care report form.

Must Ask Medication Record Questions

  1. What medications are you taking right now (name, strength, and form)?

    Exact names and strengths prevent look-alike, sound-alike errors. They also let your care team match what you report with pharmacy labels.

  2. What is the dose, frequency, and route for each medication?

    This clarifies how much to give and when, reducing the risk of under- or overdosing. It also keeps your schedule consistent across caregivers and settings.

  3. What condition is each medication for?

    Knowing the purpose helps spot duplicate therapies and drugs that no longer have a clear use. It guides safer alternatives if side effects or costs are a problem.

  4. When did you start it, and who prescribed it?

    Start dates highlight recent changes that may explain new symptoms. The prescriber name supports follow-up and shows who should approve adjustments.

  5. Do you have any drug allergies or past adverse reactions?

    Allergy and reaction history prevents serious harm and cross-reactions. It also alerts teams to avoid related ingredients during urgent care.

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