Medication and History Form


To download the form in PDF file format, select the button below.



Keep it in your wallet so it will be available in case of and emergency. Take this form to ALL doctor visits, ALL hospital visits, and when you go to pick up prescriptions.

List the names and phone numbers of your doctor, dentist, nurse practitioner or other prescriber in case they need to be contacted about your medicines.

List the name of your pharmacy, including telephone number, and location in case there are questions.


List of Medicines

Write the brand and generic name of each medicine, your dose, how often and how you take it (by mouth, under your tongue, injection, etc). If you stop taking a certain medicine, draw a line through it and list the date you stopped taking it.

List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products.

List any medicine you take only on occasion or “as needed.” (Like Motrin, Aleve, Tylenol, Nitroglycerin).


Hospital Visits

Always ask your nurse, pharmacist or doctor to help you update your list when you leave the hospital. Bring the updated form to any and all follow up appointments at your doctor’s office or hospital.


1 Jack Foster Drive

Shenandoah, IA 51601


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Clinic Hours

Monday-Friday: 7-5:00pm

Walk-In Clinic Hours

Monday-Friday: 7-6:30pm Saturday-Sunday: 9-12:30pm