"Personal Medication List Template - Wyoming Health Medical Group Llc"

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MY MEDICATION LIST
Patient Name: __________________________________
Date of birth: _________________
List all medicine you are currently taking: Prescription and over-the–counter medications (examples: aspirin, antacids) and dietary supplements
(example: vitamins) and herbals (examples: ginseng, gingko). Include medications taken as needed (examples: inhalers, nitroglycerin).
How and How Often You
Medication
Dose
Reason for taking
Date Started
Prescriber
(Brand and Generic Name)
Take the Medication
MY MEDICATION LIST
Patient Name: __________________________________
Date of birth: _________________
List all medicine you are currently taking: Prescription and over-the–counter medications (examples: aspirin, antacids) and dietary supplements
(example: vitamins) and herbals (examples: ginseng, gingko). Include medications taken as needed (examples: inhalers, nitroglycerin).
How and How Often You
Medication
Dose
Reason for taking
Date Started
Prescriber
(Brand and Generic Name)
Take the Medication