Ask your health care provider these questions about
		  each new medicine which is recommended or prescribed. Write the answers in the
		  spaces provided.
 
		Use a separate sheet for each medicine.
 
		Name of Medicine: _________________________________________________
 
		 
 
		 
		  - What are the brand and generic names of the
			 medicine? Can I use a generic form?
   
		
 
		 
 
		 
		  - What is the medicine for and what effect should I
			 expect?
   
		
 
		 
 
		 
		  - Does this drug replace any other medicine I have
			 been using?
   
		
 
		 
 
		 
		  - How and when will I use it, what amount will I use,
			 and for how long?
   
		
 
		 
 
		 
		  - What do I do if I miss a dose?
   
		
 
		 
 
		 
		  - Should I avoid any other medicines, (prescription or
			 over-the-counter), dietary supplements, drinks, foods or activities while using
			 this drug?
   
		
 
		 
 
		 
		  - When should I notice a difference or improvement?
			 When should I report back.
  
		
 
		 
 
		 
		  - Will I need to have any testing to monitor this
			 drug's effects?
   
		
 
		 
 
		 
		  - Can this medicine be used safely with all my other
			 medications and therapies? Could there be interactions?
   
		
 
		 
 
		 
		  - What are the possible side effects? What do I do if
			 a side effect occurs?
   
		
 
		 
 
		 
		  - How and where do I store this medicine?
			   
		
 
		 
 
		 
		  - Where and how can I get written information about
			 this medicine? What other sources of information can I use to learn about this
			 medicine?
  
		
 
		Call 1-888-INFO-FDA or go to
		  Be
		  An Active Member of Your Health Care Team