FREE FAMILY WORKSHEET

Medication list and reminder record

Use this companion to “Keep a clear medication list and a simple reminder record”. Tick the preparation steps, then fill in only the details you need. This is a household record, not a medical assessment.

Read the guide

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1. Before you start

Tick an item only when you have checked it. A tick records preparation, not a safety or health result.

Gather current instructions and medicine packages.Copy medicine names exactly.Include other products to show the clinician.Mark unclear instructions for the doctor.Write the date the current list was checked.Mark older lists as out of date after confirmation.Set reminders only from confirmed instructions.Make sure everyone knows a blank is not a dosing instruction.

2. Details to keep

Medication list and reminder record · Date __________________

Person / list checked date

Current medication list — continue on another copy if needed
Medicine name	Confirmed instructions (copy exactly)	Source / checked date
Medicine name 1	Confirmed instructions (copy exactly) 1	Source / checked date 1
Medicine name 2	Confirmed instructions (copy exactly) 2	Source / checked date 2
Medicine name 3	Confirmed instructions (copy exactly) 3	Source / checked date 3
Medicine name 4	Confirmed instructions (copy exactly) 4	Source / checked date 4

Confirmed reminder time / method

Reminder method and timing must come from confirmed instructions. Questions about a missed or possible repeat dose go to the doctor.

Factual record — a blank is not an instruction to take medicine
Actual event and time	Recorded by	Question for doctor
Actual event and time 1	Recorded by 1	Question for doctor 1
Actual event and time 2	Recorded by 2	Question for doctor 2
Actual event and time 3	Recorded by 3	Question for doctor 3
Actual event and time 4	Recorded by 4	Question for doctor 4