Printable worksheet
Medication list and questions for your pharmacist
One written list of everything you take is among the most useful things to carry to a pharmacy, a clinic visit or a hospital. This page gives you a blank list to print and fill in by hand, and a set of questions to tick off when you ask a pharmacist or doctor to review your medicines. Nothing you write here is stored or sent by this website, because the form is meant for paper.
Part 1. My medicine list
Include prescriptions, over-the-counter medicines, vitamins, herbal products, creams, drops, inhalers and patches. Fill in the top lines, then one row per product. Update it whenever something changes, and after every hospital stay.
Name: ______________________ Date updated: ____________ Allergies or bad reactions: ______________________________
| Medicine name (as on the label) | What it is for | Strength and directions (copy from label) | Who prescribed it | Notes |
|---|---|---|---|---|
Pharmacy name and phone: ______________________ Doctor name and phone: ______________________ Emergency contact: ______________________
Part 2. Questions to ask a pharmacist or doctor
Bring the list above, plus the actual bottles and boxes if you can. Tick each question once it has been answered, and write the answers on the list or on a separate page.
Ticks are saved only in this browser, on this device, and nothing is sent anywhere. Do not type personal health details on a shared computer. The paper copy is your record.
How to keep the list useful
Keep one copy at home where family can find it, and one in your wallet or phone. Add a new row the day you start something, and cross a row out with a date when a prescriber tells you to stop. Show the list at every appointment, not only to specialists. Using a single pharmacy where you can lets the pharmacist see the full picture, which helps with spotting duplicates and interactions.
A yearly review
Once a year, and after any hospital stay, many people put every bottle, box and supplement in a bag and take it to a pharmacist or clinician for a review. Some pharmacies offer this free of charge, and some health plans offer a review service to people who qualify. The questions in Part 2 are a good script for that conversation. For more about routines and organizers, read how to keep track of multiple medications safely.
What this page does not do
It does not say which medicines are right for you, whether doses are correct, or which combinations are safe. It does not set pill times. Only your prescriber or pharmacist can answer those questions for your situation. The medicine list is a record you control, so check it against your labels and keep it current.
Go deeper
Where this comes from
The idea of a personal medicine list covering prescriptions, over-the-counter products, vitamins and herbs, and the questions about purpose, timing, food, alcohol, missed doses and side effects, follow US Food and Drug Administration guidance on keeping a medicine list and asking about your medicines (checked October 2026 through a search summary rather than the full document). The CDC fall-prevention brochure also advises having a doctor or pharmacist review all medicines, including over-the-counter ones. The wording, layout and the extra questions about duplicates and simplifying routines were written for this page and are general prompts, not clinical guidance.