Patient Name: _______________________
Date Updated: _______________________
Primary Care Provider: _______________________
Preferred Pharmacy: _______________________
Emergency Contact: _______________________

Prescription Medications
Medication
Strength
How Often
Why I Take It
Prescribing Provider

Injectable Medications
(Examples: insulin, Ozempic®, biologics, vitamin B12 injections)
Medication
Dose
How Often
Why I Take It

Inhalers, Eye Drops & Other Medical Devices
(Examples: inhalers, nebulizers, eye drops, nasal sprays, medicated patches)
Medication/Device
How Often
Why I Use It

Over-the-Counter Medications
(Pain relievers, allergy medicine, antacids, etc.)

Vitamins & Supplements

Allergies
☐ Medications
☐ Foods
☐ Latex
☐ Adhesives
☐ Other
Details:

Notes
Be sure to carry this list with you! I suggest keeping a dedicated notebook you can put in your purse or pocket.

Healthcare Navigation Library
Knowledge is your best benefit.

1. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
2. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
3. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
4. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
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6. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
7. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
8. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
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11. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
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17. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
18. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
19. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________
20. Prescription name: ___________________ Dosage: ________ Frequency Taken: ________