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Medication Information and Sample Worksheet
Printable Medication List Worksheet

Keeping a current and accurate list of your medications and other pertinent information is important for many reasons.

For many of us, we are on an extensive list of medications and treatments. This list is often difficult to remember accurately under the best of circumstances and is virtually impossible when under duress or during a medical emergency. We also often see more than one physician. It is important that each be aware of what the other is prescribing to help eliminate duplications or medications that may conflict each other.

Having a list handy makes things so much easier. You can use the sample form available here or create one of your own, using either your word or spreadsheet program on your computer. This way they are easily updated and can be printed and shared with each of your physicians, as well as immediately handy for unexpected emergency room visits or hospitalizations. Many physicians and hospitals, in our experience, are extremely impressed by those of us that can just hand them this information to copy and place in their records.

In many areas of the country, emergency services such as rescue squads or life squads, provide “Vial of Life” kits for your use. They are placed in a designated area of your refrigerator or freezer, per their instructions and these members are trained to look there for them. Call your local department to check on availability in your area.

You can make your own as well by using a large prescription pill bottle or even a 1-pint zip-log baggie in which to place your important information. Use an index card or other similar type of paper and write something to the effect of “Important Medical Information Located In….” in big red letters and place it in a conspicuous spot, such as inside your access door, by your bedside, on your refrigerator or anywhere it is most likely to be visible to emergency personnel entering your home.

It is also recommended that you always carry this information with you either in your purse or wallet, in your car glove compartment or attached to your sun visor. You never know when it may come in handy.

Important information that should be included on any list includes, but is not limited to:

  • Name, address and phone number
  • Physician(s) name, address and phone number
  • Pharmacy name, address and phone number
  • Durable Medical Equipment (DME) Supplier (o2 supplier), name, address and phone number
  • Emergency contact information
  • Insurance information and policy numbers
  • Brief information of most significant medical diagnosis
  • Medications, dose, frequency, including those used PRN or as needed
  • Allergies and sensitivities to medications
  • All over-the-counter medications used, including vitamin, mineral and herbal preparations
  • o2 prescription information
  • Bi-PAP or C-PAP prescribing information, including settings
  • Information on whether or not you have a durable medical power of attorney, living will and/or a DNR or do-not-resuscitate order. Ideally, a copy should be kept with this information as well
  • Any and all other information you deem important if you are unable to speak for yourself

Compiled by COPD-International Community Members 

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Last modified: June 17, 2002