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Get ASCP Personal Medication List

Er-theCounter Medications Purpose or Reason Taken Dose Time(s) of Day Form (Liquid, capsule, tablet) Special Instructions Health Problems Primary Doctor Doctor’s Phone Local Pharmacy Pharmacy Phone Drug Allergies Your Phone Your Name Date Adapted by the American Society of Consultant Pharmacists (ASCP) Foundation for the Center for Medicines & Healthy Aging Instructions for Personal Medication List • Write the name of each medication you take, the reason, the dose, etc. • I.

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