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 | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|      |      |      |      |      |      |  /  /   to |      |

| | | | | | |  /  /   | |

|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 |

|      |      |(   )   -     |(   )   -     |

Pharmacies/Drug Stores

|Name |Location |Phone Number |Fax Number |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

Medical Conditions

|      |

|      |

|      |

|      |

Primary Care Physicians

| Name |Phone Number |Fax Number |

|      |(   )   -     |(   )   -     |

|      |(   )   -     |(   )   -     |

|      |(   )   -     |(   )   -     |

|      |(   )   -     |(   )   -     |

Other Physicians

| Name |Specialty |Phone Number |Fax Number |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

|      |      |(   )   -     |(   )   -     |

Insurance Coverage/Prescription Drug Discount Information

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|      |

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|      |

1035 116th Ave NE ● Bellevue, WA 98004 ● 425-688-5000 ●

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