Medicine Chart

Add new medicines when you get them. You can show the list to your health care provider and pharmacist. You may want to make copies of the blank form so you can use it again.

Name of Medication           Reason Taken               Dosage/Date Started        Time(s) of day

(Example)

Penicillin VK              To treat my strep throat         1 tablet 4 times a day          9 a.m, 1 p.m.

                                                                    250 mg started 11/22/99        5 p.m., 9 p.m.



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