My Medication Record - Overlake Hospital Medical Center
My Medication Record
Keep this list updated and with you at all times. Bring it with you to all your appointments,
when you travel, or visit a hospital or other care facility.
|Home Medication |Dose |Route |Frequency |Purpose/ |Prescriber |Start Date/ |Notes |
|Name | | | |Reason for use | |Stop Date | |
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|Date Updated: | / / | / / |
| | |Influenza given: / / |
| | |Pneumonia given: / / |
| | |Tetanus given: / / |
Patient Name:
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Personal Information
|Name |Date of Birth |Home Number |Other Phone Number |
| | / / |( ) - |( ) - |
Emergency Contact
|Name |Relationship |Home Number |Other Phone Number |
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Pharmacies/Drug Stores
|Name |Location |Phone Number |Fax Number |
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Medical Conditions
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Primary Care Physicians
| Name |Phone Number |Fax Number |
| |( ) - |( ) - |
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| |( ) - |( ) - |
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Other Physicians
| Name |Specialty |Phone Number |Fax Number |
| | |( ) - |( ) - |
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Insurance Coverage/Prescription Drug Discount Information
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1035 116th Ave NE ● Bellevue, WA 98004 ● 425-688-5000 ●
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