My Medicines
The My Medicines form is a place to write down all the medicines you take. This form can help you take your medicines the right way. Knowing what medicines you take and how you take them is important for:
- You
- Your family
- Your healthcare team
- Others who help take care of you
Important reminders:
- Keep a copy of the form with you
- Review it with your doctor or other healthcare provider when you are with them
- Update this form every time your medicines change—no matter why they changed
The form has 3 parts:
Part 1: About Me
- Ask for help with your form if you need it—your doctor, nurse, or pharmacist can help
- Don't stop taking your medicines without telling your doctor
Here you can record information about your:
- Emergency contact person
- Healthcare providers
- Pharmacy
- Allergies
Part 2: My Medicines Here you can record information about each medicine you take, including:
Medicines you take regularly, such as prescription medicines, over-the-counter (OTC) medicines, vitamins/supplements, pain relievers, etc.
Other medicines you take, such as those you take as needed
Part 3: My Vaccines Here you can record vaccines you have received ArchiTools
Part 1: About Me
My Name: _______________________________________________ My Phone: ( ______ ) ________ - ___________
My Email: __________________________________________
My Emergency Contact Person
Contact's Name:
Contact's Phone:
____________________________________________________
( ______ ) ________ - ___________
Contact's Relationship:
Contact's Email:
____________________________________________________
___________________________________________
My Doctors and Other Healthcare Providers
| Provider's Name | Provider's Specialty | Provider's Phone |
|---|---|---|
| _______ | ________ | |
| ( | __ ) _ - ___ | |
| _______ | ________ ( | __ ) _ - ___ |
| _______ | ________ | |
| __ ) _ - ___ |
My Pharmacy Information
| Pharmacy Name | Address | Phone |
|---|---|---|
| __________ | ______ ( ____ | |
| ) | _ - ____ | |
| __________ | ||
| allergic to: | ||
| ______________ |
Part 2: My Medicines
- Include medicines you take regularly: prescribed medicines, over-the-counter (OTC) medicines, infused/injected medicines, vitamins/supplements, pain relievers, etc.
- Also include any medicines you take as needed like cold/flu/allergy medicines, antacids, laxatives, eye drops, pain relievers, creams/ointments.
| Start date | Drug name and strength | Dose (The number of pills, puffs, drops, injections, etc.) EXAMPLES | When I take it | Why I take it |
|---|---|---|---|---|
| 4/9/ 22 | name of medicine (81 mg) | 1 pill | once a day with breakfast | heart |
| 7 /18/ 23 | name of injection (60 mg) | 1 injection | 2 times a year | osteoporosis |
| 8 /4/ 23 | name of inhaler (90 mcg) | 1-2 puffs | as needed | asthma |
Part 3: My Vaccines
Include vaccines for COVID, flu, pneumonia, Respiratory Syncytial Virus (RSV), shingles, tetanus, etc.
| Date | Vaccine | Where I received it | Next dose/booster due date |
|---|---|---|---|
| 10/4/2023 | COVID | My pharmacy | 10/4/2024 |
Use this page if more space is needed.
My Medicines
| Start date | Drug name and strength | Dose | When I take it | Why I take it |
|---|---|---|---|---|
My Vaccines
| Date | Vaccine | Where I received it | Next dose/booster due date |
|---|---|---|---|