PL_Pub_Notebook_Winter_2014_f - page 6

6
ProLiteracy •
Virginia Adult ESOL Health Literacy Toolkit
© 2012 VALRC
6.5.1
6.5 My Medication List
Name:___________________________________ Date of Birth:_______________________
Name of
medicine:
Date I
started
taking
it:
Color
and
shape:
What is it
for?
Dose:
How often
do I take it?
What
time(s) do
I take it?
Do not take
it with:
Example:
Advil
red
round
back pain
1 pill
200 mg
When I need
it for pain
Every 6 hours
Example:
amoxicillin
1/1/13
pink
oval
antibiotic
250mg
3 times a day
For 2 weeks
Mealtimes
Used with permission from the Virginia Adult Learning Resource Center. http://www.valrc.org/
Virginia Adult ESOL Health Literacy Toolkit
© 2012 VALRC
6.5.1
6.5 My Medication List
Name:___________________________________ Date of Birth:_______________________
Name of
medicine:
Date I
started
taking
it:
Color
and
shape:
What is it
for?
Dose:
How often
do I take it?
What
time(s) do
I take it?
Do not take
it with:
Example:
Advil
red
round
back pain
1 pill
200 mg
When I need
it for pain
Every 6 hours
Example:
amoxicillin
1/1/13
pink
oval
antibiotic
250mg
3 times a day
For 2 weeks
Mealtimes
1,2,3,4,5 7,8,9,10,11,12,13,14,15,...16
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