Medication List

Self Help Tools

List the medications used by the care-receiver with instructions on how to use them properly.

To see and print the Medication Checklist in PDF format.
Please click here

Acrobat reader allows you to see and print PDF documents, if you do not have Acrobat reader you can download it for free from this link:

Name of drug: ______________________________________________________________

Doctor who prescribed it: ___________________ Date prescribed: _____________________

What is the drug for: __________________________________________________________

Color: ___________________________________ Form: ____________________________

Shape: __________________________________ Strength: __________________________

When and how to take it: ______________________________________________________

How much to take: ________________________ How long to take it: ___________________

Other drugs to avoid: _________________________________________________________

Possible side effects: _________________________________________________________

Other Cautions: ______________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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This information is reproduced, with permison, from:

A Guide for Family Caregivers of Older Pennsylvanians