Medicine Record Form

For Keeping Track of Medications

Print this form. Write down the name of each medicine you take, the reason you take it, and how you take it, in the spaces below. Add new medicines when you get them. You can show the list to your health professionals. You may want to make copies of the blank form so you can use it again. This form was developed by the National Council on Patient Information and Education.

Name of medicine
Reason taken
Time(s) of day

Over - the - Counter Medicines (Check here if you use any of these)

  Dietary Supplements / Herbals
  Cold medicine
  Aspirin/other pain,headache, or fever medicine
  Cough medicine
  Allergy relief medicine
  Sleeping pills
  Others (names)


APA Reference
Gluck, S. (2022, January 4). Medicine Record Form, HealthyPlace. Retrieved on 2024, June 24 from

Last Updated: January 11, 2022

Medically reviewed by Harry Croft, MD

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