Use this form to record the names of your medications, purpose for taking them, dosage and timing instructions, and medication side effects to be aware of. After listing your medications, write down any questions you'd like to discuss with a health care provider.

Consider some of the following:

1. Why is the medication being prescribed?
2. How long will it be before the medicine should be helping?
3. What side effects should I watch for? Talk to your doctor if you have side effects like: Dizziness, light headedness, sleepiness during the day, confusion, or ack of coordination in the legs.
4. How much and when do I take this medicine?
5. If you're experience side effects, are there alternative options to this medication?
6. Should i take this prescription with food?
7. Are there any medications that are doing the same thing? Can any be eliminated?

Download NCOA's Medication Record Form

This project was supported, in part by grant number 90FPSG0051 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.