Fillable Medication Form PDF Details

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.

QuestionAnswer
Form NameFillable Medication Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesuniversal medication form fillable, fillable universal medication list, pdf filler medication form, universal medication form template

Form Preview Example

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 over-the-counter

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 up-to-date.

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 up-to-date on your medicines.

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 over-the-counter medicines you take!

3.Helps you—concerns may be found and prevented by knowing what medicines you are taking.

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

Watch Fillable Medication Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .