My Med List from Evidence Medicine.com
When completed, print and take to ALL doctor visits, all emergency room visits,
all hospitalizations (especially surgeries - request this be placed on the front of your
chart) and when vacationing.  Keep multiple copies and repeatedly review for errors.
Your Name:
Last Name   
First Name:  
Birthdate    Month: ---- January February March April May June July August September October November December    Day     -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23 24 25 26 27 28 29 30 31    Year: 19     20

Do you take any Blood Thinners (including Aspirin) ?
 Aspirin 81 mg daily  Aspirin 100 mg every other day
 Aspirin 325 mg daily Aspirin 75 mg daily

 Warfarin (coumadin)

 Clopidogrel (plavix) 75 mg

Cardiac Medications: (review each medicine in each category - you might not be familiar with the category names)
Beta-Blockers
None Atenolol (tenormin) Metoprolol (lopressor, toprol xl) Propanolol (inderal) Carvedilol (coreg)              N/A 3.125 mg 6.25 mg 10 mg 12.5 mg 20 mg 25 mg 37.5 mg 50 mg 75 mg 100 mg 150 mg 200 mg                         N/A once daily twice daily three times daily four times daily other
ACE Inhibitors 
None Lisinopril Captopril (capoten) Enalapril (vasotec) Quinapril (accupril) Ramipril (altace)                                                 N/A 2.5 mg 5 mg 7.5 mg 10 mg 15 mg 20 mg 30 mg 40 mg                             N/A once daily twice daily three times daily
Calcium Chanel Blockers
None Amlodipine (norvasc) Diltiazem (cardizem, dilacor, tizac) Nifedipine (procardia, adalat) Other Verapamil (calan, veralan)     N/A 2.5 mg 5 mg 7.5 mg 10 mg 15 mg 30 mg 45 mg 60 mg 90 mg 120 mg 180 mg 240 mg 300 mg 360 mg 480 mg Other                            N/A once daily twice daily three times daily four times daily other
Diuretics (‘water pills’)
None Furosemide (lasix) Hydrochlorothiazide (HCTZ) Spironolactone (aldactone) Triamterene and HCTZ (dyazide) Other (list below)        N/A 2.5 mg 5 mg 10 mg 12.5 mg 20 mg 25 mg 37.5 mg 37.5 mg / 25 mg 40 mg 50 mg 60 mg 80 mg 100 mg 120 mg 160 mg    N/A once daily twice daily three times daily four times daily other
Statin Cholesterol Meds
None Simvastatin (zocor) Atorvastatin (lipitor) Pravastatin (pravachol) Fluvastatin (lescol) Other (see below)                                    N/A 5 mg 10 mg 20 mg 20 mg 30 mg 40 mg 80 mg                                N/A once daily twice daily three times daily four times daily other
Other Cholesterol Meds
None Niacin (over the counter) Niacin (niaspan) Gemfibrizol (lopid) Other (see below)                                N/A 500 mg 600 mg 1000 mg 1200 mg 1500 mg 2000 mg                            N/A once daily twice daily three times daily four times daily other
Other Prescription Medications / Over the counter pain relievers, supplements, vitamins, etc.







Medication Allergies or Side Effects - DESCRIBE THE REACTION


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