The Universal Medication Form

How Does This Form Help You?

• By helping you and your family members remember all of the medicines you are taking

• By providing your doctor(s) and others with a current list of ALL of your medicines; doctors also need to know the herbals, vitamins and over-the-counter medicines you take

• By increasing your medication safety by knowing what medicines you are taking

Frequently Asked Questions

• What medications do I list on the form? 

List all current medications including prescriptions, over-the-counter drugs, and herbal remedies

• What do I do with the form once I have filled it out?  

Keep it in your wallet or purse at all times so it is readily available in case of an emergency; also, take the form with you to all healthcare visits and show it to all of your healthcare providers

• Why should I use this form? Many reasons!

   } It will save you time at the doctor’s office because when they

   ask what medications you are taking, all you have to do is

   show the form  

   } It will reduce confusion by helping you communicate all

   medications to your doctor and decrease the chances that you

   forget to mention all of your medications 

   } It will increase your medication safety because your

   providers will have more accurate information and it will

   help prevent them from prescribing duplicate medications or  

   interacting medications

   } It also helps improve your medication safety by 

   communicating your allergies to your providers

• What if my doctor changes my prescriptions? 

Then you need to update your form. Ask your provider or your pharmacist to help you update your form. If you fill out a new form, discard the old form.

• Who should use the Universal Medication Form?  

Anyone who takes several medications each day needs to use this form.

English Form

Spanish Form

Patient Information Brochure