In our ever-changing technological age, many aspects of our lives have become automated. One area that has seen particular technological advances is the medical field. Physicians and patients now have a number of tools at their disposal to improve communication and ensure accuracy when it comes to medication prescriptions. The fillable medication form is one such tool that can simplify the process for both pharmacists and patients alike. In this blog post, we will discuss what a fillable medication form is, how it works, and some advantages it offers over traditional prescription slips. We hope this information will be helpful to you in your own personal health care journey.
Below are a few facts you might want to check out just before you start dealing with the fillable medication form.
| Question | Answer |
|---|---|
| Form Name | Fillable Medication Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | universal medication form fillable, fillable universal medication list, pdf filler medication form, universal medication form template |
UNIVERSAL MEDICATION FORM
|
Fold this form and keep it in your wallet |
Date form started: |
|||
|
Name: |
|
|
Address: |
|
|
Phone Number: |
|
|
|
|
|
Birth Date: |
|
|
Medical Record #: |
|
|
Emergency Contact/Phone numbers: |
|
|
||
|
|
|
|
|
|
|
IMMUNIZATION RECORD (Record the date/year of last dose taken, if known) |
||||
|
TETANUS |
FLU VACCINE(S) |
|
|
|
|
PNEUMONIA VACCINE |
HEPATITIS VACCINE |
|
OTHER |
|
|
|
|
|
|
|
|
Allergic To /Describe Reaction: |
|
|
Allergic To /Describe Reaction: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: Prescription and
medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include
medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE
DIRECTIONS:
Use patient friendly directions.
(Do not use medical abbreviations.)
DATE
STOPPED
Notes:
Reason for
taking /
Doctor Name
Refer to back of form for directions, benefits of using the form, and how to get more copies.
(09/07) |
Page _______ of _______ |
UNIVERSAL MEDICATION FORM
Patient:
1.ALWAYS KEEP THIS FORM WITH YOU. You may want to fold it and keep it in your wallet along with your driver’s license. Then it will be available in case of an emergency.
2.Write down all of the medicines you are taking and list all of your allergies.
3.Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
4.WRITE DOWN ALL CHANGES MADE TO YOUR MEDICINES on this form. If you stop taking a certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask your Doctor, Nurse, Pharmacist, or family member to help you to keep it
5.In the NOTES column, write down the name of the doctor who told you to take the medicine(s). You may also write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).
6.When you are discharged from the hospital, someone will talk with you about WHICH MEDICINES TO TAKE AND WHICH MEDICINES TO STOP TAKING. Since many changes are often made after a hospital stay, a new form should be filled out. When you return to your doctor, take your new form with you. This will keep everyone
HOW DOES THIS FORM HELP YOU?
1.This form helps you and your family members remember all of the medicines you are taking.
2.Provides your doctor(s) and others with a current list of ALL of your medicines. Doctors need to know the herbals, vitamins, and
3.Helps
SC Pharmacy Association
SC Emergency Medical |
South Carolina Society of |
Service Association |
Health System Pharmacists |
For copies of the UNIVERSAL MEDICATION FORM visit
the South Carolina Hospital Association web site at www.scha.org.
(09/07) |
Developed by AnMed Health and South Carolina Hospital Association 2004 |