Medicine Tracker - Maryland Poison Center

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Medicine Name. Form ... Lost track of your meds? Think you may have taken a double dose? Call the poison center at 1-800
Patient Name

Medicine Tracker

Share this information with your doctors and pharmacists at each visit

Medicine Name

Form (pill, injection, etc)

How much and when

Pharmacy Name and Phone

Prescribing Doctor

Reason for taking

Start/Stop Dates

Remember to include ALL medicines: prescription, over-the-counter, vitamins, dietary supplements

Lost track of your meds? Think you may have taken a double dose? Call the poison center at 1-800-222-1222 to speak with a nurse or pharmacist anytime, day or night.

6. Can I stop taking it if I feel better?

____________________________________________

5. Is it safe to safe to take it with other medicines or vitamins?

Phone #

Other health Care Providers & Phone Numbers

4. Are there any side effects?

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Phone #

2. How and when should I take it? And for how long?

____________________________________________

1. What is my medicine called and what does it do?

Critical health issues:

Poison First Aid Inhaled Poison Get to fresh air right away and avoid fumes. Open doors and windows wide.

Care Provider

3. What if I miss a dose?

Phone #

Poison on the Skin Take off clothing the poison touched. Rinse skin with running water. Wash off with soap and water.

Care Provider

Poison in the Eye Run lukewarm tap water over eye for 10 min. Do not force the eyelid open.

My Primary Doctor:

Swallowed Poison Do not make the person vomit, drink or eat unless told by a poison expert.

My Health Information

Questions to ask your doctor/pharmacist Fold Here First

Allergies:

_______________________

____________________________________________

My Name

Name of Medicine

Health & Medication Record

__________________________

What Type of Reaction I have from it

My Phone #

_________________________________________________

__________________________

What Type of Reaction I have from it

My Emergency Contact

_________________________________________________

______________________

Name of Medicine

Emergency Contact Phone #

What Type of Reaction I have from it.

______________________

Other Allergies (non-medication related):

My Pharmacy

______________________

Second Fold Here

Pharmacy Phone #

Third Fold Here

Name of Medicine

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