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Your medicines.
FREE PRINTABLE WORKSHEET
Your medicines.
In one place.
Fill this out from your medication containers and existing instructions. Ask your pharmacist or clinician about anything unclear.
No personal information is entered or stored on this page. Print the blank worksheet and complete it on paper.
CHALICE HEALTH FOUNDATION · MEDICATION LIST
Name:
Last updated:
Allergies and reactions / details to confirm:
| Medicine / product name | Strength & form | How I take it Use existing instructions | Questions / details to confirm |
|---|---|---|---|
My pharmacy and contact number:
My care team and contact number:
Before your next visit
- Bring this list and your medication containers, if possible.
- Include products taken only as needed.
- Mark unclear details for review. Do not guess.
- Update the date when your care team changes your instructions.
For organizing information only. Do not start, stop, or change a medicine based on this worksheet. Review questions with your pharmacist or clinician.
Informed by AHRQ’s discussion of medication review and communication. Resource prepared September 29, 2026.