Universal Medication Form

McLeod Health
Florence, South Carolina, USA


This two-page form can be used by patients to register information about their medication use, allergies, and immunization record. The form can also help prevent adverse drug events (ADEs) and improve communication between health care providers, patients, and families.



Reconciliation is a process of identifying the most accurate list of a patient's medications. It requires comparing a patient's existing medications with those physicians might order during admission, transfer, or discharge. The key to the reconciliation process is an accurate Universal Medication Form carried by the patient, which can help to prevent adverse drug events (ADEs).





  1. Always keep this form with you.
  2. Take the form to ALL doctor visits and ALL medical testing (lab, x-ray, MRI, CT, etc). Take this form to ALL pre-assessment visits for admission or surgery and ALL hospital visits (ER, inpatient admission, outpatient visits).
  3. Update this form as changes are made to your medications. If a medication is stopped, draw a line through it and record the date when it was stopped. If help is needed ask the physician, nurse, or pharmacist to help you fill out this form.
  4. In the "COMMENTS" column, record things like the name of the doctor who told you to take this medication. You may also add the reason for taking the medication (e.g., high blood pressure, high blood sugar, high cholesterol, etc.). Always keep this form with you.
  5. Tell your family, friends, and neighbors about the benefits of using this form.
When you are discharged from the hospital, you will get an updated form. This will be reviewed with you and you will be given a copy. When you return to your doctor, take your updated form with you. Always keep this form with you. This will keep everyone up to date on your medication.
for patients: 



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