MyMedications LIst (Tribal)

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, herbal products,
and traditional cultural medicines that you
are currently taking.
How to use your MyMedications List:
•

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

•

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 a community health
aid, doctor, dentist, pharmacist, or a hospital.
• Update this list any time you make a change
to what you take.
•

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.

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, Herbal Products, and Traditional Cultural Medicines
Name of
Medication

Reason
Taken

Dose and
Directions

Example: metformin

Diabetes

1000 mg twice a day

Example: oxymetazoline (Afrin)

Congestion

Two sprays in each nostril no more
than twice a day

Prescribing
Provider

Notes

Dr. Jill Smith

Take with food

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,
Vitamins, Supplements, Herbal Products, and Traditional Cultural Medicines
Name of
Medication

Reason
Taken

Dose and
Directions

Prescribing
Provider

Notes

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