Health Literacy Universal Precautions Toolkit, 2nd Edition

Medicine Reminder Form

[Microsoft Word file Microsoft Word version - 111.76 KB]

Icon: The sun.

What medicines do I need to take?
Each day, follow this schedule:

 

Morning Medicines

Medicine name (generic and name brand) and amount Why am I taking this medicine? How much do I take? How do I take this medicine?
       
       
       
       
       
       
       

 

Icon: A clock with its hands at noon.

What medicines do I need to take?
Each day, follow this schedule:

Afternoon Medicines

Medicine name (generic and name brand) and amount Why am I taking this medicine? How much do I take? How do I take this medicine?
       
       
       
       
       
       
       

 

Photograph of the sun setting.

What medicines do I need to take?
Each day, follow this schedule:

 

Evening Medicines

Medicine name (generic and name brand) and amount Why am I taking this medicine? How much do I take? How do I take this medicine?
       
       
       
       
       
       
       

 

Icon: A crescent moon wearing a nightcap.

What medicines do I need to take?

Each day, follow this schedule:

 

Bedtime Medicines

Medicine name (generic and name brand) and amount Why am I taking this medicine? How much do I take? How do I take this medicine?
       
       
       
       
       
       
       

 

A question mark.

What other medicines can I take?

 

  Medicine name and amount How much do I take? How do I take this medicine?
If I need medicine for a headache      
If I need medicine to stop smoking      
If I need medicine for
__________________________
     
If I need medicine for
__________________________
     
If I need medicine for
__________________________
     
If I need medicine for
__________________________
     
If I need medicine for
__________________________
     
If I need medicine for
__________________________
     

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Medicine Reminder Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool16b.html