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Medication Information Form

West Tennessee Healthcare is a leader in providing and promoting safe healthcare. We encourage all people to keep an up-to-date record of all medicines they are taking. Keep the list handy in case of an emergency. It is important that your doctor have a complete list so they can review it for any possible concerns with mixing medications. The form is especially helpful if you need to be in the hospital. Helping to ensure safe medical care is as easy as Click, List, and Take.

Click to download and print your own form (click here for English and Spanish are available). Print as many as you need or want for various members in your family who take medications every day. Complete the form and keep it up-to-date.

List all prescriptions, over-the-counter medications, vitamins, and herbals that you are taking.

Take the form with you to all doctor visits (including the dentist and eye doctor) and when you need to have tests or go to the hospital. Ask the doctor to update the form at each visit.

If you have a medical emergency, take the completed form with you to the Emergency Room and give it to your doctor or nurse.

  • You may wish to keep the form:
  • In your wallet, purse, backpack, briefcase, or pocket
  • In your car's glove box
  • Wherever you keep your medical insurance card


West Tennessee Healthcare  |  620 Skyline Drive, Jackson, TN 38301  |  731-541-5000
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