Medication Log Form PDF Details

If you’re taking a variety of medications – either prescription or over-the-counter – it’s vitally important to keep track of when and how you take them. Keeping a medication log form is an easy way to stay organized, ensuring that you never miss any doses or accidentally double up on medicines. In this blog post, we’ll explain the importance of keeping a medication log form and provide tips on how to use one effectively so that you can manage your medications in an organized manner.

QuestionAnswer
Form NameMedication Log Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshealth sustaining medication form pa, pennsylvania department of health health sustaining medication form, life sustaining medication form, medication log

Form Preview Example

MEDICATION LOG

 

 

 

 

 

55 Pa. Code §3270.133; §3280.133; §3290.133

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE PRINT

Page

 

 

 

of

 

 

 

Child’s Name:

 

 

 

 

 

 

 

 

Medication:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescription

Non-Prescription

 

 

 

Refrigeration Required:

YES

 

NO

 

If Prescription, Prescriber’s Name:

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

 

 

Dosage Amount:

 

 

 

 

Time to Administer:

 

a.m.

 

p.m.

 

 

 

 

times/day

 

Dates for Administration:

From

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

Date

 

 

 

 

 

 

 

 

 

Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold medication, contraindications:

I give permission to administer medication to my child as stated above.

Parent SignatureDate

 

 

FACILITY STAFF COMPLETE THIS SECTION

 

 

 

 

 

 

Date

Time

Amount of

 

 

Administered

Administered

Medication

Comments/Reactions

Staff Initials

(mm/dd/yyyy)

(a.m. / p.m.)

Administered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This information is confidential and may not be shared or released without the parent’s written permission.

CY 862 10/04

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