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/clinical/pted/hffy/medication/4560.hffy

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Clinical Hub,Patient Education,Health and Nutrition Facts For You,Medication Instructions

Health Information and Medication/Vaccination Reference Card (4560)

Health Information and Medication/Vaccination Reference Card (4560) - Clinical Hub, Patient Education, Health and Nutrition Facts For You, Medication Instructions

4560



Health Information and Medication/Vaccination Reference Card

This handout gives you a personal record of your health information. With the help of your health care
team, complete the information and keep it with you at all times.

Use pencil rather than pen to fill out the Medication/Vaccination Reference Card. Then you can update
medicine changes or add vaccinations or boosters when you receive them.

ξ Keep this Card in your wallet in case of any emergency. You may also use it at your doctor
appointments.

ξ Update the information and bring this card with you to every clinic visit. You may want to show it
to all of your providers so everyone knows what medicines you take.

ξ Take your medicines only as instructed by your health care team.

ξ Never stop taking prescribed medicines without first talking with your health care team.

ξ If you are having side effects from your medicines, tell your provider before you stop taking the
medicine.

ξ Check with your pharmacist or provider before starting any new over-the-counter or herbal
medicines on your own.


Health Information and Medication/Vaccination Reference Card
Name______________________________MR#_____________________Clinic_____________________Phone_________________
Primary Care Providers _________________________,MD ________________________,NP/PA _________________________
Pharmacy Phone _____________________
Drug or Food Allergies ________________________

Last Physical Exam
Last PAP/Pelvic
Last Flexible Sigmoidoscopy
Other doctors you see _________________________
___________________________________________

Vaccinations date/
year
date/
year
date/
year
date/
year
date/
year
Tetanus/Diphtheria
Mumps
Measles
Rubella
Hepatitis B
Pneumococcal
Influenza
H1N1 (Swine Flu)
Zostavax (shingles)

Guidelines for Getting your Prescription Renewed

If your prescription bottle indicates you have refills available, call your pharmacist. If you have
no refills left and you need a renewal, please contact the pharmacy and they will send a request to
your provider for refills.

1. Be prepared to provide:
 Your name
 Date of birth
 Name of medicine (please spell)
 Dose
 Directions for use as stated on the bottle
 The name of the health care provider who prescribed it
 When you need the next dose of medicine

2. Please request renewals at least 48 hours before you need your prescription.

3. Renewals for a narcotic or controlled substance will not processed by clinic staff after
3:00 p.m. Monday through Friday, after clinic hours or on weekends. Please allow extra time
for the provider to respond.

Thank you for your help in this matter.


Your health care team may have given you this information as part of your care. If so, please use it and call if you
have any questions. If this information was not given to you as part of your care, please check with your doctor. This
is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each
person’s health needs are different, you should talk with your doctor or others on your health care team when using
this information. If you have an emergency, please call 911. Copyright © 8/2016 University of Wisconsin Hospitals
and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#4560.


Please cut or tear along perforated line.



MEDICATION NAME

DOSE

TIMES TAKEN

PURPOSE

PRESCRIBED BY















































































































Include all medications—prescription, over-the-counter, and herbal. (see reverse side)