The document provides instructions for patients to fill out a "My Medicines" form with details of all their prescribed, non-prescribed, and over-the-counter medications. It advises bringing the completed form along with original medication containers to their appointment at Tallaght Hospital. It includes a sample "My Medicines" table to list each medication along with dosage, frequency, and reason for taking it. Patients are asked to provide their contact details and allergies.

1. MY MEDICINES
Details to be filled in
My Medicines is a list of all the medicines
you take and some of their details. To
help us treat you safely, please fill in the
My Medicines information on the back
of this page and bring it with you when
you come to Tallaght hospital. We also
ask that you bring your medicines in their
original boxes and containers (if you have
them) along with you to the hospital.
To fill out My Medicines you need all
your medicines in front of you including
prescribed, non-prescribed and over the
counter medicines. If you don’t know
what medicines you take or you need
help filling out My Medicines, ask your
pharmacist, doctor, friend or relative
to help you.
Please fill in your details below and
answer the question on allergies.
Read the example on how to fill out
My Medicines (on the back of this page)
and then fill in the My Medicines table
straight after.
Name_______________________________________________
Date of birth _________________________________________
Phone number _______________________________________
Name of next of kin and their phone number
____________________________________________________
Today’s date is _______________________________________
My pharmacy is ______________________________________
Phone number _______________________________________
My family doctor is ____________________________________
Phone number _______________________________________
Are you allergic to any medicines? No Yes (If yes, please fill in the box below.)
Please name the medicine you are allergic to:
Please describe what happened when you used the medicine:
When did this happen? Month: Year:
This is a patient empowerment document and belongs to the patient. A copy can be filed in the Patient Healthcare Record.

2. Name of medicine The strength How much I take
each time
How many times a
day I take it
I take it
everyday (Y/N)
Why I take it
ABC tablets 25 mg 2 tablets Twice a day, morning
and evening
Yes For my heart
Name of medicine The strength How much I take
each time
How many times a day
I take it
I take it
everyday (Y/N)
Why I take it
Example of how to fill out MY MEDICINES:
Please fill in your medicines:
This is a patient empowerment document and belongs to the patient. A copy can be filed in the Patient Healthcare Record.