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, 

and herbal products that you are 

currently taking. 

How to use your MyMedications List: 

• List every prescription medication, 

OTC medication, vitamin, supplement, 

and herbal product 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 your 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: ____________________________________ 

Pharmacy: ___________________________________________ 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) Medicat

Vitamins, Supplements, and Herbal Products 

Name of Medication 

Reason Taken 

Dose and Directions 

Prescribing Provider Notes 

Example: metformin Diabetes 1000 mg twice a day Dr. Jill Smith Upsets m

with foo

Example: oxymetazoline 

(Afrin) Congestion Two sprays in each nostril no more than twice a day OTC Do not u

three da

continue
continued from previous page 

My Current 

continued from previous page 

Prescription Medications, Over-the-Counter (OTC) Medicat

Vitamins, Supplements, and Herbal Products 

Name of Medication 

Reason Taken 

Dose and Directions 

Prescribing Provider Notes 

For more information: bit.ly/Medicines-Risk 

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