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Jones Memorial Hospital / Participate in Your Safety / Universal Medication Form

Universal Medication Form

What You Should Know

Jones Memorial Hospital is continuing our efforts to improve Patient Safety. One of the focus areas for this initiative is medications and how important it is to have an accurate list of any and all medications—both prescription and over the counter—with you at all times. Having this information with you when you are seeking medical care will help your provider to accurately prescribe treatment. A form has been provided below. Please print it off, fill it out, and have it with you at all times.

  • Download the form. Print it and always keep it with you. You may want to fold it and keep it in your wallet along with your driver’s license. Then it will be available in case of an emergency.
  • Write down all of the medicines you are taking and list all of your allergies.
  • Take this form to ALL doctor visits, when you go for tests and ALL hospital visits.
  • Write down all changes made to your medicines on this form. If you stop taking a certain medicine, draw a line through it and write the date it was stopped. If help is needed, ask your Doctor, Nurse, Pharmacist, or family member to help you to keep it up-to-date.
  • In the Notes column, write down the name of the doctor who told you to take the medicine(s). You may also write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).
  • When you are discharged from the hospital, someone will talk with you about which medicines to take and which medicines to stop taking. Since many changes are often made after a hospital stay, a new form should be filled out. When you return to your doctor, take your new form with you. This will keep everyone up-to-date on your medicines.

How Does this Form Help You?

  1. This form helps you and your family members remember all of the medicines you are taking.
  2. It provides your doctor(s) and others with a current list of ALL of your medicines. Doctors need to know the herbals, vitamins, and over-the-counter medicines you take!
  3. It also helps you when talking to your doctor. If you have concerns, they may be prevented by knowing what medicines you are taking.