MyMedications List 

Date Last Updated: _______________________ 

MM/DD/YYYY 

The MyMedications List is a way for you to 

keep track of all prescription medications, 

over-the-counter (OTC) medications, 

vitamins, supplements, herbal products, 

and traditional cultural medicines that you 

are currently taking. 

How to use your MyMedications List: 

• List every prescription medication, OTC 

medication, vitamin, supplement, herbal 

product, and traditional cultural medicine 

that you are currently taking. 

• Also list things you have stopped taking 

because of allergic reactions or for other 

reasons (like side efects, cost, or if it did 

not work). 

• Bring this list with you any time you go 

for health care, like to a community health 

aid, doctor, dentist, pharmacist, or a hospital. 

• Update this list any time you make a change 

to what you take. 

• Review this list with your health care 

provider (such as a doctor, pharmacist, 

nurse practitioner, or physician assistant) 

to identify medications that may increase 

your risk of a fall or afect your ability to 

drive safely. 

• Work with your health care provider to 

complete the MyMedications Action Plan 

and adjust any medications as needed. The 

MyMedications Action Plan is available at 

bit.ly/CDC-MedicinesRisk. 

Keeping an 

up-to-date list of 

your medications 

that you—or 

others—can easily 

access is important 

for health care visits 

and in case of an 

emergency. 
 

 

My Information 

Name: ________________________ DOB: ________________ Phone: ______________________ 

Current Address: ___________________________________________________________________ 

Emergency Contact: ___________________ Emergency Contact Phone: _____________________ 

Relationship: _________________________ 

My Health Care Providers 

Primary Care Provider: __________________________________ Phone: _____________________ 

Other Provider 1: ______________________________ Provider 1 Phone: ______________________ 

Specialty: ____________________________________ 

Other Provider 2: ______________________________ Provider 2 Phone: _____________________ 

Specialty: ____________________________________ 

Pharmacist: __________________________________ Phone: ______________________________ 

My Medical Conditions 

Medical 

Condition 

Date 

Diagnosed 

Example: high blood pressure 09/01/2020 

Medications I Don’t Use Because 

of Allergies or Other Problems 

Name of 

Medication 

Describe 

Reason 

Example: penicillin Rash, hives 

Example: glyburide Lightheaded, low blood 

sugar 
 

My Current Prescription Medications, Over-the-Counter (OTC) Medications, 

Vitamins, Supplements, Herbal Products, and Traditional Cultural Medicines 

Name of 

Medication 

Reason 

Taken 

Dose and 

Directions 

Prescribing 

Provider Notes 

Example: metformin Diabetes 1000 mg twice a day Dr. Jill Smith Upsets my stomach, have to 

take with food 

Example: oxymetazoline (Afrin) Congestion Two sprays in each nostril no more 

than twice a day OTC Do not use for more than three days in a row 

continued on next page, if needed 
continued from previous page 

My Current Prescription Medications, Over-the-Counter (OTC) Medications, 

Vitamins, Supplements, Herbal Products, and Traditional Cultural Medicines 

Name of 

Medication 

Reason 

Taken 

Dose and 

Directions 

Prescribing 

Provider Notes 

For more information: www.cdc.gov/transportationsafety/older_adult_drivers/meds_fs/index.html

Page number _______ of _______ 

2023