My Medication Record

QualityTool

My Medication Record

Description

Patients can use this form to keep track of all their medicines and supplements. Patients are encouraged to show it to their doctors and pharmacist at each visit and ask them to check for unnecessary duplications or medicines that could interact to cause harm.

This form includes the following fields to be completed by the patient:

  • Name of medicine or product
  • How much do I take?
  • When and how do I take it?
  • Why do I take it?
  • Start date

Developer:

University of Arizona Center for Education and Research on Therapeutics (CERT)

Funding Sources:

Agency for Healthcare Research and Quality; U.S. Department of Health and Human Services

History

Release Date: 2004
Original Summary: November 2004
Last Updated: 01/15/14

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