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Patient and Visitors’ Center

Universal Medication Form

The Universal Medication Form is a tool developed for the consumer to keep track of all of the prescription medications, over-the-counter medications, and herbal supplements that a person takes when they are at home. You can get these forms from many places, such as hospitals, physician offices, pharmacies, and health fairs. Take the form with you and give copies to each of your doctors, your pharmacist and your dentist. Have them help you update the form if your medications change.

Consumers: Keep an updated copy of the form in your wallet/purse so it will be available at all times, even in the case of an auto accident. This will allow emergency medical services (EMS) and emergency departments to have access to this vital clinical information. Take it with you to the hospital when you are scheduled for inpatient admission or outpatient visits. Give it to the emergency medical workers if you have to call 911. If you are admitted to the hospital, your medications may change. When you are discharged, many hospitals will give you a new form that lists the new medications and any old medications that you are to continue taking. Make sure to keep the form updated and take it with you to share with everyone who had the old form.

How should the Universal Medication Form be used?

You can use the form and write on it, or you can download it to your computer and keep it electronically. (We suggest you download a blank copy and name it "Universal Medication Form." Then customize a form for each of your family members and save it as "Mom Universal Medication Form," "Dad Universal Medication Form," etc.)

Editable Version

This version allows you to fill out the form on your computer. Please note: you cannot save a completed copy of this form after you fill it out. Please print your completed form if you would like a copy for your records.