COUNCIL ON AGING - SOUTHERN CALIFORNIA My Medication List Patient Name & Address _____________________________________________________________________ Primary Physician: _________________________ Phone Number: __________________________________ Pharmacy Name/Address: ___________________ Phone Number: __________________________________ Health Issues ______________________________________________________________________________ _________________________________________________________________________________________ Drug Allergies _____________________________________________________________________________ _________________________________________________________________________________________ List all prescription medications (Rx) and all over-the-counter (OTC), including vitamins or other nutritional supplements, pain relievers, antacids, laxatives and herbal remedies. When requested, update this list to take to your MD and/or Pharmacist. MEDICATIONS Type (circle one) Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Source: Reed Rosling, R.Ph. independence and peace of mind Council On Aging - Southern California | 714-479-0107 | www.coasc.org To learn more about FAST, please see our article on page 76 714-479-0107 Supporting well-being, Sponsored by the Financial Abuse Specialist Team (FAST) 714-619-2129 coasc.org Answers Guide 23/24 75 Name Strength Form (tablet, etc.) Dosing A.M. / P.M. Notes CUT OUT # POST IN A VISIBLE PLACE CHECKLISTS MY MEDICATION LISThttp://www.coasc.org