Printables: The Prescription History List Form

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Printable Forms for Your Life: The Prescription History List Form

The Prescription History List is a quick and convenient way to keep track of past prescription medications taken by your entire family.
Print Home Ever After’s Prescription History List Form now.
Print one sheet for each family member.  Keep all the sheets together; try paperclipping, putting them into a folder or 3-ring binder, or whatever works best for you.  Keep the Prescription History Lists in an easy-to-access location, like in the basket with your medicines or medicine cabinet.

Each time you pick up a prescription, log it on the Prescription History List along with the month and year.  Don’t forget to include what illness the medicine is being taken for.  During medicine use, make note of any allergic or adverse reactions and side effects experienced.

Take the Prescription History Lists with you to doctor appointments or emergency visits.  Your prescription history is valuable information that should be part of your medical record so that your doctor can see how you have handled certain medications in the past.  The handy allergy tracker at the top will prevent your doctor from prescribing a possibly life-threatening medication.

Note: Please request that your doctor or nurse make a copy of your Prescription History List or scan it and put it into your medical record.  The disclosure at the top of the form (“Attention Medical Personnel”) serves as your written permission for them to add the sheet to your medical record, saving you an extra step – just sign your name next to the disclosure.

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