Dr. Irene's Health and Nutrition Tidbits



Instructions for Section 5A: Prescription Medication Log

Sorry, the Personal Health Record Binder



The purpose of this form is to have a record of medicine your doctor has ordered for you, why it was ordered, and whether it helped you.  Doctors that you visit need to know all the medication you currently take or have taken in the past.

In the first and second column you record the date started and stopped.  If there is no “stopped” date, it is assumed that you are still taking the medication.  Make sure you put a date in that column when you stop taking a medication.

In the third column, “Medication & Dose”, copy exactly what the label says.  If your doctor has told you something different than what you see on the label, call the doctor to clarify.  Write in this column exactly how you are supposed to take the medication.  (Record all telephone conversations in your telephone log).    In the fourth column, indicate the doctor’s name under “who ordered”.

In the fifth column “Reason”, put the medical condition or symptom for which the drug was prescribed.  The sixth column is very important.  Always document any problems with the medication and call your doctor if side effects are serious or prevent you from taking the medication.  Also record if it helped.  In the last column record the page of the doctor’s visit during which this medication was prescribed.

If at any time your dose or frequency of the medication changes, put a “date stopped” date on the line of the old dose and start a new line.  If this was due to a telephone conversation rather than a visit, record the conversation on your telephone log and under the last column, “details”, write “telephone log”. 

If you need more space for any column, use more than one line. When you understand these instructions, place them in Section 10A for future reference.




Prescription Medication Log


Date Started

Date Stopped

Medication & Dose

Who Ordered


Did it Help?

Any Problems?

Details: Section 3





Dr. Smith

High BP

BP was up




50 mg Daily



and down





Dr. Smith


Helped but BP then up




50 mg BID








Dr. Smith


BP good-10/1/00




250 mg BID








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