Your Medicine: Be Smart. Be Safe. (with wallet card)

Medicine Wallet Card

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

Download the print version ( PDF Version - 1.1 MB).

My name ___________________________________
Contact information ___________________________
___________________________________________
___________________________________________

Prescription Medicines

Name and How Much Medicine Color What It Is For Date Began Taking How Much To Take and When Do Not Take With
(example)
Tetracycline
250 mg
White Respiratory infection 2/8/2011 1 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: __________________________________________________________
___________________________________________________________________
___________________________________________________________________

Page last reviewed July 2015
Internet Citation: Medicine Wallet Card. July 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/safemeds/walletform.html