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My Dietary Supplement and Medicine Record

This document provides a template for recording information about dietary supplements, prescription drugs, and over-the-counter medicines. It includes fields to document the product name and active ingredients, description, dosage, usage instructions, start and stop dates, reason for use, and contact information for the healthcare provider who recommended it. An example is provided showing calcium carbonate supplements. Tips are given such as filling out the record with all products used and sharing it with healthcare providers. Questions to ask about supplements or medicines are also listed.

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qvrlenarasegt
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337 views3 pages

My Dietary Supplement and Medicine Record

This document provides a template for recording information about dietary supplements, prescription drugs, and over-the-counter medicines. It includes fields to document the product name and active ingredients, description, dosage, usage instructions, start and stop dates, reason for use, and contact information for the healthcare provider who recommended it. An example is provided showing calcium carbonate supplements. Tips are given such as filling out the record with all products used and sharing it with healthcare providers. Questions to ask about supplements or medicines are also listed.

Uploaded by

qvrlenarasegt
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

My Dietary Supplement and Medicine Record Name

Date

Enter all of the Dietary Supplements, Prescription Drugs, and Over-the-Counter Medicines that You Take.
What I’m Using
Dietary supplement, prescription drug What It Looks Like
or over-the-counter medicine (product Color, shape, size, How Much Start/Stop Who Told Me to Use
name and active ingredients) markings, etc. Dose How to Use and When Dates Why I’m Using and How to Contact

EXAMPLE: Calcium – White oval tablet 500 mg Take orally, 1 time a day 9/15/18 Bone health Dr. S. Smith
Calcium Carbonate with food to present (800) 555-1212

For more information from the NIH Office of Dietary Supplements,


visit our website at: https://ods.od.nih.gov or email us at [email protected] Page 1 of 3
Allergic Reactions or Other Problems I’ve Had with Any Dietary
Additional Notes
Supplement, Medicine, Food, Skin Product, etc.

Questions I Should Ask About Tips for Using My Dietary Supplement


Dietary Supplements or Medicines and Medicine Record
• Are there any special directions for using this product? • F ill in this record with any dietary supplements,
• S hould I avoid any other dietary supplements, medicines, or prescription drugs, or over-the-counter medicines you
take. Note: Dietary supplements include vitamins, minerals,
treatments while using this product?
herbs and botanicals, amino acids, enzymes, and many
• S hould I avoid any foods, beverages, other substances, or activities other products.
while using this product?
• P rint and share this record with your doctors, pharmacists,
•W
 hat are the possible side effects from this product? Is there or other health professionals at all your visits.
anything I should watch for? What should I do if I get a side effect?
• What should I do if I miss a dose?

For more information from the NIH Office of Dietary Supplements,


visit our website at: https://ods.od.nih.gov or email us at [email protected] Page 2 of 3
My Dietary Supplement and Medicine Record (continued) Name Date

Enter all of the Dietary Supplements, Prescription Drugs, and Over-the-Counter Medicines that You Take.
What I’m Using
Dietary supplement, prescription drug What It Looks Like
or over-the-counter medicine (product Color, shape, size, How Much Start/Stop Who Told Me to Use
name and active ingredients) markings, etc. Dose How to Use and When Dates Why I’m Using and How to Contact

For more information from the NIH Office of Dietary Supplements,


visit our website at: https://ods.od.nih.gov or email us at [email protected] Page 3 of 3

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