Your Medicine: Be Smart. Be Safe. Medicine Wallet Card

You can learn more about how to take medicines safely by reading this guide. It answers common questions about getting and taking medicines and has handy forms that will help you keep track of information.

Show this card to your doctor or pharmacist. To print more copies, visit www.ahrq.gov and type "Your Medicine" in the search box.

Select to download the print version ( PDF file PDF version - 1.1 MB ). Plugin Software Help.

My name ___________________________________
Contact information ___________________________
___________________________________________
___________________________________________

Prescription Medicines

Name and How Much MedicineColorWhat It Is ForDate Began TakingHow Much To Take and WhenDo Not Take With
(example)
Tetracycline
250 mg
WhiteRespiratory infection2/8/20111 tablet
4 times a day
9 a.m., 1 p.m.,
5 p.m., 9 p.m.
Antacids or dairy products
 
 
 
 
     
 
 
 
 
     
 
 
 
 
     
 
 
 
 
     

Blood type: ________________________________

Medical conditions: __________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Emergency Contact

Name: ___________________________________
Home phone: ______________________________
Work phone: _______________________________
Cell phone: ________________________________

Nonprescription medicines

___ Cold or cough medicines
___ Aspirin or other pain relievers
___ Allergy relief medicines
___ Antacids
___ Sleeping pills
___ Laxatives
___ Diet pills
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________

Medicines I should not take because of bad reactions or allergies: ________________
___________________________________________________________________
___________________________________________________________________

Vitamins, herbals, and supplements

___ Vitamins (type): __________________________________________________
___________________________________________________________________
___________________________________________________________________

___ Glucosamine chondroitin
___ St. John's wort
___ Ginkgo biloba
___ Ginseng
___ Other: __________________________________________________________
___________________________________________________________________
___________________________________________________________________

Current as of April 2011
Internet Citation: Your Medicine: Be Smart. Be Safe. Medicine Wallet Card. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/safemeds/walletform.html