Academy of the Holy Family – Health Department

 

                               My Medicine Record – Part 1    
            

Please translate all information into English

My Personal Contacts

 

Name                              _____________________________________________

Date of Birth                    _____________________________________________                                            

Phone Number                 _____________________________________________                                            

Cell Phone                      _____________________________________________                                            

Emergency Contact       _____________________________________________                                                                                                                               

Name                             _____________________________________________                    

Relationship                    _____________________________________________                                            

Cell Phone                      _____________________________________________                                            

Phone Number                 _____________________________________________                                            

Primary Care Physician _____________________________________________                                                                                                                             

Name                              _____________________________________________                                            

Phone Number                 _____________________________________________                                            

Pharmacy / Drugstore    _____________________________________________                                                                                                                               

Name                              _____________________________________________                                            

Phone Number                 _____________________________________________                                            

                                                                                             

Allergic Reaction or Other  Problem I’ve Had With…

any medicine, dietary supplement, skin cleaner, tape…
___________________________________________________________

 

My Medical Conditions and Operations                                                           

                                                

Questions I Should Ask About Medicine or Dietary Supplements

•      When should I report back to the Doctor?                                                                    
• Should I avoid any drinks, foods, other substances, or activities while using this medication?
•    Are there any special directions for using this medication?                                           
•     Should I avoid any other medicines, dietary supplements, or treatments while using this medication?               
• What should I do if I miss a dose?
• What do I do if I use too much of this medication?

Names of Non-Prescription Medicines I am Taking:                           

Cold or cough Medicine   _______________________________________                  

Pain Reliever                  _______________________________________                                                   

Allergy Relief Medicine   _______________________________________                                    

Antacids                       _______________________________________                                                                   

Other: __________________________________________________                       ________________________________________________________

________________________________________________________                        ________________________________________________________

 

Names of Vitamins, Herbals, and Supplements I am taking:

Vitamins (type): _____________________________________

____ Glocosamine Chondrotin

____ Ginkgo Biloba

____ St. John's Wort

____ Ginseng

Other:  ____________________________________________

 

Medicines I should not take because of bad reactions or allergies: __________________________________________________
__________________________________________________

 

 

My Medicine Record - Part 2					Name:
	What I'm Using Prescription medication name or over-the-counter medication name	What it Looks Like        color, shape, size, marking, etc.	How           Much	When to Use	Start /  Stop Dates	Why Am I Using	Who told Me to Use
... Enter ALL prescription medicine (include samples), over-the-counter medicine, and dietary supplement …
Ex	XXXX/xxxxxxxxxx	20 mg pill; small, white, round	40 mg; use 2-20 mg pills	2 times a day; take at 8 a.m. & 8 p.m.	1/15/2006	Lowers blood pressure; check blood pressure once a week; blood test on 4-15-06	Dr. X
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						These are my medicines as of: