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Medicine Chart

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Medicine Chart

Write down the name of each medicine you take, the reason you take it, and how you take it, in the spaces below. Add new medicines when you get them. You can show the list to your health care provider and pharmacist. You may want to make copies of the blank form so you can use it again.

Medicine Chart

Name of Medicine Reason Taken Dosage/Date Started Time(s) of day
Penicillin VK
250 mg
To treat my strep throat 1 tablet 4 times a day
started 11/22/99
9 a.m., 1 p.m.
5 p.m., 9.p.m.
       
       
       
       
       
       
       

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