MEDICATION LIST
Bring this list, and your medicines, to every appointment, pharmacy visit, and hospital stay.

ABOUT ME
Name: [Full name]
Date of birth: [Date]
Phone: [Your phone number]
Emergency contact: [Name, relationship, and phone]
Who helps with my medicines: [Name and phone of a caregiver, or I manage my own]
Health conditions: [Each ongoing condition, such as diabetes, heart failure, or asthma]
Weight: [Weight and the date measured]
Kidney or liver problems: [Any a clinician has told me about, or none known]
Pregnant or breastfeeding: [Yes, no, or not applicable]

ALLERGIES AND REACTIONS
Medicine allergies: [Medicine and what happened, such as hives, swelling, or trouble breathing, or none known]
Side effects that stopped a medicine: [Medicine and what happened, or none]
Other allergies: [Latex, foods, contrast dye, insect stings, or none known]

PRESCRIPTION MEDICINES
Include inhalers, patches, injections, eye and ear drops, creams, and anything taken once a week or once a month.
One line for each: name and strength; dose and when; how it's taken; what it's for; prescriber; date started
1. [Name and strength]; [How many, how often, and what time of day, or when needed]; [By mouth, inhaled, patch, injection, drops, or cream]; [What it's for, in my own words]; [Prescriber]; [Month and year started]
2. [Next prescription medicine, in the same order]

OVER-THE-COUNTER MEDICINES
Pain relievers, allergy, sleep, stomach, and cold medicines
1. [Name and strength]; [How much and how often]; [What it's for]

VITAMINS, SUPPLEMENTS, AND HERBAL PRODUCTS
1. [Name and amount]; [How often]; [Why I take it]

RECENTLY STOPPED, CHANGED, OR ON HOLD
1. [Medicine]; [Stopped, changed, or on hold, and the date]; [Why, such as a side effect or no longer needed]; [Who decided, and when to restart if on hold]

MY PHARMACY AND PRESCRIBERS
Pharmacy: [Name and phone]
Main clinician: [Name, practice, and phone]
Other prescribers: [Name, specialty, and phone, or none]

LAST REVIEWED
Reviewed with: [Clinician or pharmacist's name and the date]
Next review: [Date, or at the next visit]

CLINICIAN REVIEW: MEDICATION RECONCILIATION
For the clinician or pharmacist at a visit, admission, transfer, or discharge
Reason for review: [Routine visit, admission, transfer, discharge, or a new prescription]
Sources used: [Patient or caregiver, the medicines themselves, pharmacy dispensing record, clinic record, specialist letter, or discharge summary, with dates]
Discrepancies found: [Each difference between the sources and what the person actually takes, or none]
Checks: [Duplicates, interactions, allergies, and doses for age, weight, and kidney function]
Decision for each discrepancy: [Continue, change, stop, start, or hold, with the reason]
Medicines on hold: [Medicine, why, and when and by whom it will be restarted]
Who was told: [Patient or caregiver, pharmacy, other prescribers, and the next care setting]
Updated list given: [Printed, sent to the patient portal, or both, and the date]
Reviewed by: [Name, role, date]