CardioTrack
My medication list for an appointment
Print this blank form, or use your browser's Print menu to save it as a PDF. Use extra sheets when needed. This page has no data-entry fields and sends no medicine information.
Read the appointment preparation guide | Explore CardioTrack's clinician summary
Name: _____________________________________ Date checked: ____________________
Allergies or reactions (describe what happened): ________________________________________________________
Contact to use in an emergency (optional): _______________________________________________________________
Include prescriptions, nonprescription medicines, vitamins and supplements. Copy the label carefully. Write "unsure" rather than guessing. Keep stopped medicines and recent changes clear.
| Medicine name and formulation | Strength | Label dose and timing | Actual use / current status | Purpose / changes / questions |
|---|---|---|---|---|
My three questions for the doctor or pharmacist
1. ____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________
3. ____________________________________________________________________________________________________
Bring original medicine containers when possible. Ask your doctor or pharmacist about changes, reactions and medicine-specific missed-dose advice. This form does not choose treatment or assess safety. Keep completed copies secure.