Current Medication List

Keep this list updated and bring a copy to every medical appointment, pharmacy visit, and emergency room visit. This is especially important for GLP-1 patients, as drug interactions with injectable medications must be carefully managed.

Full Name:

Date of Birth:

Primary Care Provider:

Provider Phone:

Last Updated:

ALLERGIES & DRUG REACTIONS

Allergy 1:Reaction:

Allergy 2:Reaction:

Allergy 3:Reaction:

Allergy 4:Reaction:

Prescription Medications

Medication Name	Dose	Frequency	Reason / Condition	Prescribed By	Start Date

Over-the-Counter (OTC) Medications

Medication Name	Dose	Frequency	Reason

Supplements & Vitamins

Supplement Name	Dose	Frequency	Reason

Pharmacy Information

Pharmacy Name:

Address:

Phone:

Prescription Delivery?

Emergency Contacts

Contact 1 Name:

Relationship / Phone:

Contact 2 Name:

Relationship / Phone: