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Medication Reconciliation Form

Click here to download the Medication Reconciliation Form

What is the Universal Medication Form?
The Universal Medication Form is a chart to help you and your family members keep a current record of information that physicians need to know. This record includes immunizations, allergies, prescribed medications, and any vitamins, herbal supplements or over-the-counter medicines.
I have printed this form, now what do I do?
Fill in all the blanks on the form that apply to you. List all medications and the physician(s) who prescribed them. Include any vitamins, herbal supplements, or over-the-counter medicines. Write neatly so that others can read your form.
When do I use this form?
Bring this form with you whenever you visit your physician, go for tests, or when you are admitted to the hospital. Make sure that the form is up-to-date.
Where should I keep this form?
Keep this form in your wallet or purse so that it is always with you. This will help healthcare providers locate the form in case of an emergency.
I have been to the doctors and my medications have changed, should I scratch them out on the form?
Yes. Whenever you change medications, scratch through the old medication and write in the new information.
I have just been discharged from the hospital and there are a number of changes. What should I do?
Fill out a new form. There are often many medication changes following a hospital stay. Before you leave the hospital, someone will tell you which medicines to take and which medicines to stop taking. When you return to your physician, take your new form with you.