Good Day Pharmacy Ear Drops

Write down the name of each medication you take, the reason you take it, how you take it, and the form (tablet, capsule, liquid), color and shape of the medication. In the last column, write down side effects and any special instructions your doctor or pharmacist have told you about. List all prescription medications and all over-the counter medicines, including vitamins or other nutritional supplements, pain relievers, antacids, laxatives, and herbal remedies. Add new medicines when you start taking them.

Carry this list with you at all times in your purse or wallet. Show this form to your doctors whenever you have an appointment. Bring this form with you to your pharmacy when you get a prescription filled. You may want to make copies of the blank form so you can use it again.

Medication Record

Your Name and Address:
Your Primary Doctor:
Other Doctor:
Primary Doctor's Phone Number:
Other Doctor's Phone Number:
Pharmacy's Phone Number:
Your Pharmacy:
Your Health Problems:
Your Drug Allergies:

Name of Medication	Purpose or Reason Taken	Dose	Time(s) of Day	Form, Color, and Shape	Side Effects or Special Instructions
Example: Vasotec 5 mg.	To treat my high blood pressure	One tablet twice a day	7 a.m. 7 p.m.	white, round tablet	May cause dizziness during the first days of therapy.

American Society of Consultant Pharmacists