New Medication Form - Health Literacy Now

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My New Medication Form

Name              ______
Allergies

New Pill name How much? _

How often do I take it?

What is this pill for?                 ____

What time of the day do I take it?

         Morning            Noon                Night           Bedtime

            ___      _      _

What are the main side effects?

1. ______

2.

3.

Do I need to take the pill with food?

Yes             No _

Do I need any blood test for this new pill?   _

____

Do I need to change my diet for this pill?

_

Do I need to watch out for any signs? _

____________________

Who do I contact if I have any questions?

Name Phone _