FREE SERVICE: DOCTORS and PATIENTS: SAVE TIME:
Have Your Patients Complete My Med List and My Med History (See Tabs Above)       

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


User agrees that EvidenceMedicine.com and its operators cannot be held responsible in any way for
errors or omissions on this medical history. All medical histories: verbal, written, electronic or other are
prone to errors. All users (patients and medical professionals) should always suspect the possibility of
inaccuracies in any form of medical history and should repeatedly check for errors.
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