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

• Prescription Medication and Provider: List the brand name of the prescription medications that the person you are caring for currently takes. This includes both Alzheimer medications and medications used for other medical conditions. Also, provide the name of the doctor who prescribed it, even if the doctor is other than the primary care physician.
• What is it for?: List the disease (Alzheimer’s) or symptom (memory loss) that the drug is being given for.
• Strength: List the strength of the individual tablet, capsule, or liquid concentration
• What does it look like? (form, color, shape, imprint, number): Write down whether it is a tablet or capsule, what shape it is, the color, and any markings/number it has on it that can help identify the pill

Over-the-Counter Medication Information

• Over-the-counter Medication: List the name of the over-the-counter or non-prescription medication.
• What do you take it for?: Record the reason why the medication is used.
• Strength: List the strength of the medication. For example: 10 mg, 250 mg, etc.
• How much, how often, and when do you take it?: Try to be as specific as possible, include how many times is it taken and if it is taken daily or as needed. For example: One tablet two times a day every day, 2-3 tablets two times a day as needed for 2-3 days a week, etc.
• How well does the medication work?: Record if the medication is helping or not. If not, please mention the problems the person is having with the medication.

Vitamins and Herbal Supplements

• In this table please list any herbal supplements or vitamins that the person you are taking care of takes.
• The information asked here is same as that for over-the-counter medication.

Updating your form suggestions

• After a visit to the doctor or pharmacy if there are any changes you can hand write it on the form, but update the form online at least once every 4 months.
• It may be useful to save your old medication record forms for future reference if needed.
• When a prescription medication is discontinued, do not remove it entirely from the form. Write in the stop date in the last column titled "start/stop date"
• When a dose or directions on how to take the medication change, leave the old entry for that prescription medication as is, add the stop date to that entry, and then type in a new entry with a the new dose/directions and the new start date for that dose/directions
• When starting out a medication like Aricept or Namenda that require the dose to be slowly increased, when the dose is increased add the new dose as a new entry. In the old entry write in the stop date. Again, do not remove the entry with the lower dose. Here is an example:

Important Tips

• Use "tab" button to go to the next blank or box.
• Do not hit "Enter" button. If you hit "enter" by mistake, it may submit the form but you can click the "edit" button and get back to filling the form.
• Make sure to hit "Continue" at the bottom of the form after filling out the form.
• See below for instructions on how to save the page to your computer.
• Click "edit" to update the form. You must be online to do this.
• Useful tips are also available at the beginning of the Personal Medication Record Form itself.
• If you would rather fill the form by hand instead of doing it online, you can download and print the blank form from "additional links".

How to Save the Page

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Page updated: 10/25/07