ࡱ> U@ 'Xbjbj UZ8JJJJ$----D .Bp.....;0;0;0m?o?o?o?<?@cA$CREpAE20";022AJJ.._A3332"J8..m?32m?3834I6|6.. Dk-2:67|A0B6DF3DF$6JJJJDF6;0L0630,0;0;0;0AA$$&3&Prescription Medications Start Date Name of Medicine Brand name Generic name too if available  Prescribed By Dose (mg, units, puffs, drops) When Do You Take It? How many times per day? Morning and night? After meals? Purpose Why do you take it? Important Comments (e.g. danger signs, side effects, drug-drug, drug-food interactions, stopped taking*) Stop Date Monitoring Required (e.g. lab test every _____ weeks) Notes Date reviewed; Date Updated1/1/05Feel BetterDr. Help5 mg2 times morning, nightulcerMakes me dizzyBlood test every 4 weeks5/18/05 - Reviewed by Dr. Help and Changed Dose to 10 mg.*Always refer to physician and pharmacist input and the detailed drug sheets provided with each medication for a complete list of potential side effects/danger signs/interactions. USE PENCIL Whenever you see a doctor, including your primary care physician and any specialists, review and update this medication list. After any hospitalization, check with your doctor to review this medication list. Patient Medication Card Prototype Information about you Questions to Ask My Doctor Your name: _______________________________________________________ ____________________________________________ Address:__________________________________________________________ ____________________________________________ Birth Date:____________ Blood Type: _________ Weight:________ Height: _______ ____________________________________________ ____________________________________________ name phone ____________________________________________ Pharmacy: _______________________ ______________ ____________________________________________ ____________________________________________ Primary care doctor: _______________________ ______________ ____________________________________________ ____________________________________________ ____________________________________________ Other physicians: _______________________ ______________ ____________________________________________ (specialists) _______________________ _____________ ____________________________________________ ____________________________________________ Emergency Contact: _______________________ ______________ ____________________________________________ Medical Conditions Vaccinations (date of last immunization) oasthma oheart disease odiabetes ohigh blood pressure Influenza:__________ Pneumococcal:__________ ocancer okidney disease oother_________________ MMR:____________ Tetanus/diphtheria:__________ Over-the-Counter Medications Discontinued Medications or Products (check all that you use regularly) Allergy relief, antihistaminesHerbals, dietary supplementsMedication, Food, EnvironmentalDiscontinued Medications, Allergy, Side Effects, Reaction or Intolerance Experienced (symptoms, severity, dates)AntacidsLaxativesAspirin/other pain, headache, or feverSleeping pillsCold/cough medicinesVitamins, mineralsDiet pillsOthers (list below): Developed by the Massachusetts Coalition for the Prevention of Medical Errors Insert Logo Here  !$%&.08acqrx   g h i j t u ûõݵõݵݫݫݙhF5CJaJh _hFCJ hpCJhF hFCJhpCJaJhFhFCJaJ hFCJhp5CJaJhFhF5CJaJhMbhFaJ hq?CJ hq?5CJ9 %&8Cabcqrx  i j $Ifgd $Ifgd,9$If$If@&gdE&Xj t u     7 q r s Ff0 $IfgdFf"$ l z $Ifa$gd Pl z $Ifgd,9 l z $Ifgd,9$If      7 p q r s t } ~     µµµ¨ hFCJ hFCJ(hMbhFaJhp5OJPJQJ^JhF5OJPJQJ^JhMbhF5OJPJQJ^JhF5OJPJQJ^JaJ#hMbhF5OJPJQJ^JaJhFhphpCJ:s t u v w x y z { | } ~  Ff6Ff>  l z $Ifgd,9 $Ifgd$If Ff&Ff. l z $Ifgd,9 $Ifgd$If Ff%Ff  l z $Ifgd,9$If $Ifgd Ff/ $IfgdFf* l z $Ifgd,9$If Ffz>Ff9 $Ifgd$IfFf4 l z $Ifgd,9    FfjHFfrC l z $Ifgd,9 $Ifgd$If                    FfZRFfbM l z $Ifgd,9 $Ifgd$If     " x : L M T c t u    ż~tkdSOhq?!jh~(.5CJUmHnHu h~(.5CJh~(.h\OCJh~(.h\O5CJh~(.hPZ65CJh~(.h:W5CJh~(.hPZ6CJh~(.h:WCJ h\O5CJ hq?5CJh~(.hq?5CJh@hq?CJ hq?5CJ hoCJh3hq?CJh3h6hCJh3hoCJhMbhFaJhF hFCJ      ! 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"~(.C\/PZ6,9q?CH[7P"S@T:WFWp\ _MbWgf6hK-jpmq{3~P-pwt1't],N)+!BFJ[oI3E\O~/Zh@R%bqit7qrstuvwxyz{|}~      !"O  )Ff$%&'<OPQR]rstuvwxyz|}~!(aJaJaJ@Acrobat PDFWriterLPT1:Acrobat PDFWriterAcrobat PDFWriterAcrobat PDFWriterAcrobat PDFWriter%g@@4@@UnknownGz Times New Roman5Symbol3& z ArialG5  hMS Mincho-3 fg;Wingdings5& zaTahoma"Ah33w딦%  % Y24d 3QHX(?t1Medication Chart Pamela Moorejustinb$      Oh+'0  ( D P \ ht|Medication Chartdedi Pamela Mooreartameame Normal.dotejustinb2stMicrosoft Word 10.0@F#@ߏL@oV@oV%՜.+,D՜.+,< hp|   e  { Medication Chart TitleH<\t|_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnce̮9)Coalition site - Patient Medication Card_REBrickman@mhalink.orgntEffie Brickmannffi  !"#$%&'()*+,-/0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FаkData .R_1Table^hFWordDocumentUZSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q