You can use the Universal Medication Form from Aiken Regional Medical Centers to list information about your medication use, allergies and immunization record in one easy-to-keep document. This form can also help you and your physician prevent adverse drug events, and improve communication between you and your family and your healthcare providers.

How Does This Form Help You?

  1. It helps you and your family members remember all of the medicines you are taking.
  2. It provides your doctor(s) and others with a current list of all your medicines. Doctors need to know the herbals, vitamins and over-the-counter medicines you take.
  3. It helps reveal concerns that may be prevented by knowing what medicines you are taking.

Instructions for Patients

  • Always keep this form with you. You may want to fold it and keep it in your wallet along with your driver’s license. Then it will be available in case of emergency.
  • Write down all of the medicines you are taking and list all of your allergies.
  • Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
  • Write down all changes made to your medicines on this form. If you stop taking a certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask your doctor, nurse, pharmacist or family member to help you keep it up-to-date.
  • In the NOTES column, write down the name of the doctor who told you to take the medicine(s). You may also write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).
  • When you are discharged from the hospital, someone will talk with you about which medicines to take and which medicines to stop taking. Since many changes are often made after a hospital stay, a new form should be filled out. When you return to your doctor, take your new form with you. This will keep everyone up-to-date on your medicines.

Download the Universal Medication Form