Clover's Group

Medications and Health

Faith · Hope · Love · God's Grace

Last updated: ____________

Condensed Guide

Medications and Health

The medication picture, seven-day log, symptom tracker, and questions for the care team.

3 pages · ~25 min · Prints on ≤ 3 Letter pages

CLOVER’S GROUP

Faith · Hope · Love · God’s Grace

Allergies & current medications

page 1 / 3

Allergies & reactions

Known allergies

Adverse reactions / medications to avoid

Current medications

Medications

Medication 1

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Seven-day medication log (refill)

page 2 / 3

Bring a fresh copy to every appointment. Do not change medication without guidance from the appropriate licensed clinician.

Doses

Dose 1

Date

Scheduled time

Medication

Dose

Given time

Initials

Skipped / refused

Reason (if skipped)

Notes

Symptom log & questions for the care team (refill)

page 3 / 3

Symptom observations

Observations

Observation 1

Date

Time

Symptom or change observed

Severity (0 none – 10 severe)

Duration

Possible trigger

Action taken

Response

Temperature

Blood pressure

Pulse

Oxygen (if used)

Blood sugar (if used)

Clinician contacted

Instructions received

Priority questions

Questions

Question 1

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed