MY MEDICATION LIST My Medication List Patient Name & Address_____________________________________________________________________ Primary Physician: _________________________ Phone Number: __________________________________ Pharmacy Name/Address: ___________________ Phone Number: __________________________________ Health Issues ______________________________________________________________________________ _________________________________________________________________________________________ Drug Allergies _____________________________________________________________________________ _________________________________________________________________________________________ Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Rx OTC Name Dosing A.M. / P.M. Notes Source: Reed Rosling, R.Ph. 714-479-0107 coasc.org Sponsored by the Financial Abuse Specialist Team (FAST) To learn more about FAST, please see our article on page 76 # POST IN A VISIBLE PLACE Type (circle one) MEDICATIONS Form Strength (tablet, etc.) CUT OUT 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.http://www.coasc.org