Instructions on how to complete a Personal Medication Record form

Table of Contents

Personal Medication Record Form (SAMPLE)


Date First Filled: Day/month/year in any form.

Date Updated: Write in the date you change any information in the form and update it

Patient’s date of birth: Write in the date of birth of the person you are taking care of.

Drug Allergies: List medications that the patient has taken in the past that has caused an allergic reaction and the date it occurred.

Food Allergies: List any food products that the patient is allergic to. Ex: Peanuts, lactose intolerant


Patient and Caregiver Contact Information: Enter the following information for both the patient and the caregiver: name, address, home telephone number, cell phone number, and e-mail address.

Physician and Pharmacy Contact Information: Enter the following information for your primary care physician and the primary pharmacy you use to get your prescription medications filled: Name of the physician and name of the pharmacy, address, telephone number, and e-mail address if available. The primary care physician is the one who provides all the care overall besides Alzheimer’s. The primary pharmacy is the pharmacy you use to get most of the prescriptions filled.

Questions that caregivers can ask the health care provider: We have made a list of 10 questions that will be very useful for caregivers to ask the doctor or pharmacist.


Prescription Medication Information


Over-the-Counter Medication Information


Vitamins and Herbal Supplements


Updating your form suggestions


Important Tips

How to Save the Page

[in the menu click File] 1. In your browser's menu, click [File]. [under File, click Save As...] 2. Under File, click [Save as...].
[click Yes] 3. If the browser asks if you would like to save it anyway, click [Yes]
[click Save] 4. Save the file in a safe, but convenient location like your desktop, floppy drive or USB drive.


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College of Public Health and Health Professions, University of Florida