Medicine Chart
Write down the name of each medicine you take, the
reason you take it, and how you take it, in the spaces below.
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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