MEDICATION FORM OF

MEDICATION FORM OF
YOUR NAME HERE
Complete this form, make copies and keep them in your Aware in Care kit. At the hospital, share your
completed Medication Form when you are asked to provide a list of medications. Fill out a new form when your
prescriptions change and keep this updated version in your kit.
Important names and numbers:
Care Partner
Relationship
Phone/Fax
Parkinson Doctor or Neurologist
Phone/Fax
Primary Care Physician
Phone/Fax
Pharmacy
Phone/Fax
Basic Information:
I was diagnosed with Parkinson’s disease in (year).
I have a Deep Brain Stimulation device. □ Yes □ No
I also have the following conditions (check box):
□Constipation
□
□Depression
□
□Heart
□
Disease
□Melanoma
□
□Urinary
□
Incontinence
□COPD
□
□Diabetes
□
□Hypertension
□
□Osteoarthritis
□
□Other:
□
Medication List:
List all medications you are taking for Parkinson’s and other conditions, including over-the-counter medications and
supplements.
Medication
Dosage
Frequency/
Condition Treated
Started
Timing
The National Parkinson Foundation’s Aware In Care campaign aims to help people with Parkinson’s get the best care
possible during a hospital stay. For more information please visit www.awareincare.org or call 1.800.4PD.INFO (473-4636).