My Medicine Record

This record will help you keep track of your medicines and dietary supplements.

Once you have filled out the form, keep a printed copy with you at all times. Share the record with your doctors, pharmacists, or other health professionals at all visits.

My Medicine Record (PDF - 331KB)

My Medicine Record contains:

  • Medicine Chart (page 1)
    Use this page to record the names of your medicines and dietary supplements.  Always carry it with you.
  • Personal Information Sheet (page 2)
    Use this page to help you remember the questions to ask your health care professionals and the information you need for filling in medical forms. Record your pharmacy number, emergency contact, and more.
  • How to Use My Medicine Record (pages 3-4)
    Instructions and help with recording your medicines and supplements.

"My Medicine Record" is in PDF format.  You will need the free Adobe Acrobat Reader disclaimer icon to view it.

  • You can print or download the entire "My Medicine Record" at once or you can print "My Medicine Record" in parts.
  • The Medicine Chart and Personal Information Sheet can be printed and filled in by hand with a pencil. You can also fill it in and print it using Adobe Acrobat Reader, but you will not be able to save your changes. You can also save a blank copy of the form on your computer.

If you have Adobe Professional software on your computer, you can save the file, fill it out, and then save your completed form on your computer.

Page Last Updated: 03/14/2019
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