Free Patient Medication List Template
Patient Medication List
Prepared by: [Your Name]
Hospital: [Your Company Name]
Introduction:
A Patient Medication List is a critical tool for healthcare providers to ensure safe and effective management of a patient's medications. It includes detailed information about each medication prescribed, facilitating communication and reducing the risk of medication errors.
Patient Information:
-
Name: Elizabeth Mabel
-
Date of Birth: January 1, 1980
-
Contact Information: mabel@pt.com
Medication Details:
|
Medication Name |
Dosage (Strength) |
Frequency |
Route |
|---|---|---|---|
|
Lisinopril |
10 mg |
Once daily |
Oral |
|
Metformin |
500 mg |
Twice daily with meals |
Oral |
|
Atorvastatin |
20 mg |
Once daily at bedtime |
Oral |
|
Aspirin |
81 mg |
Once daily |
Oral |
|
Levothyroxine |
75 mcg |
Once daily on empty stomach |
Oral |
|
Vitamin D |
1000 IU |
Once daily |
Oral |
Prescribing Doctor:
-
Dr. Emily Smith, MD
Start Date:
|
Medication Name |
Start Date |
|---|---|
|
Lisinopril |
January 1, 2020 |
|
Metformin |
March 15, 2010 |
|
Atorvastatin |
October 5, 2015 |
|
Aspirin |
February 20, 2018 |
|
Levothyroxine |
May 10, 2012 |
|
Vitamin D |
Ongoing |
Purpose/Indication:
|
Medication Name |
Purpose/Indication |
|---|---|
|
Lisinopril |
Hypertension |
|
Metformin |
Type 2 diabetes |
|
Atorvastatin |
Hyperlipidemia |
|
Aspirin |
Cardiovascular protection |
|
Levothyroxine |
Hypothyroidism |
|
Vitamin D |
Vitamin D deficiency |
Special Instructions:
-
Levothyroxine: Take on an empty stomach
-
Vitamin D: Take with food
Pharmacy Information:
|
Pharmacy Name |
Contact Information |
|---|---|
|
Maplewood Pharmacy |
Phone: 555-987-6543 Address: 456 Oak Avenue, Maplewood, USA |
Allergies/Side Effects:
-
None known
Additional Notes:
-
Patient is compliant with medications.
-
Please review annually or as medications change.
