MyMedications List (English)

My Medications List

Date Last Updated:
___________________

The MyMedications List is a way for
you to keep track of all prescription
medications, over-the-counter (OTC)
medications, vitamins, supplements,
and herbal products that you are
currently taking.
How to use your MyMedications List:
•

List every prescription medication,
OTC medication, vitamin, supplement,
and herbal product that you are
currently taking.

• Update this list any time you make a
change to what you take.
•

Also list things you have stopped taking
because of allergic reactions or for
other reasons (like side effects, cost,
or if it did not work).

• Bring this list with you whenever you
go for health care, like to your doctor,
dentist, pharmacist, or a hospital.
•

Review this list with your healthcare
provider (such as a doctor, pharmacist,
nurse practitioner, or physician
assistant) to identify medications
that may increase your risk of a fall
or affect your ability to drive safely.

•

Work with your healthcare provider to
complete the MyMedications Action
Plan and adjust any medications as
needed. The MyMedications Action Plan
is available at bit.ly/CDC-MedicinesRisk.

Center
Contro
Nation
Preven

My Information
Name: ________________________ DOB: ________________ Phone: ______________________
Current Address: ___________________________________________________________________
Emergency Contact: ___________________ Emergency Contact Phone: _____________________
Relationship: _________________________

My Healthcare Providers
Primary Care Provider: __________________________________ Phone: _____________________
Other Provider 1: ______________________________ Provider 1 Phone: ______________________
Specialty: ____________________________________
Other Provider 2: ______________________________ Provider 2 Phone: _____________________
Specialty: ____________________________________
Pharmacist: ___________________________________________ Phone: _____________________

My Medical Conditions

Allergies or Other Problems
with Medications

Medical
Condition

Date
Diagnosed

Name of
Medication

Describe
Problem

Example: high blood pressure

09/01/2020

Example: penicillin

Rash, hives

Example: glyburide

Lightheaded, low blood
sugar

My Current Prescription Medications, Over-the-Counter (OTC) Medications,
Vitamins, Supplements, and Herbal Products
Name of
Medication

Reason
Taken

Dose and
Directions

Prescribing
Provider

Notes

Example: metformin

Diabetes

1000 mg twice a day

Dr. Jill Smith

Take with food

Example: oxymetazoline
(Afrin)

Congestion

Two sprays in each nostril no more
than twice a day

OTC

Do not use for more than
three days in a row

continued on next page, if needed

continued from previous page

My Current Prescription Medications, Over-the-Counter (OTC) Medications,
continued from previous page
Vitamins, Supplements, and Herbal Products
Name of
Medication

Reason
Taken

Dose and
Directions

Prescribing
Provider

Notes

Page number _______ of _______
For more information: bit.ly/CDC-MedicinesRisk
June 2022