For the interactive version of this Personal Medication Record, please go to: http://alzonline.phhp.ufl.edu/pmr/

Name Address Telephone Number E-mail address
Patient        
Caregiver        
Primary Care Physician        
Primary Pharmacy        
Prescription Medication and Prescriber What is it for? Strength What does it look like? (form, color, shape, imprint, number) How much, how often, and when do you take it? How well is the medication working? Start date / Stop date
             
             
             
             
             
             
             
             
Over The Counter Medication What is it for? Strength How much, how often, and when do you take it? How well does the medication work?
         
         
         
         
         
         
Vitamins and Herbal Supplements What is it for? Strength How much, how often, and when do you take it? How well does the medication work?