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Carissa Spisak holds a doctorate in speech-language pathology.

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Large-Print Medication Administration Record

Medication administration record, printable, in large print: an 8-page PDF of blank forms for the people who give someone their medications, such as family members or helpers who share the job. A month on one landscape page: each medication and the time of day it is given down the side, days 1 to 31 across, and a box for the initials of whoever gave each dose. Also an as-needed record, a page for notes when a dose was not given, and a page that matches every set of initials to a name and a signature.

$2.99printable PDF

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  • Instant download
  • 8 pages in each PDF
  • US Letter and A4
  • Fill-in fields need the free Adobe Acrobat Reader

You buy it in our Etsy shop and download the files right after checkout.

  • One whole landscape page of the monthly medication record, filled in with an invented example: a long name, date of birth, allergies and month, five example medication lines, and handwritten initials for October 1 to 11, with the letters R, A and O in three boxes.
  • Cover: the Large-Print Medication Administration Record, with the monthly record filled in with five example medication lines and blue initials for October 1 to 11, in front of the as-needed record.
  • The five form pages in the file: the monthly record lines 1 to 12 and lines 13 to 24, the as-needed record, the not given and other notes page, and the who gives medications page.
  • The monthly record filled in: a long example name, date of birth, allergies and month at the top, five medication and time lines with invented medication names, and initials in the day boxes for days 1 to 11.
  • Close-up of the day boxes: initials from two people, one set in each day's box, and the letters R, A and O where a dose was not given as usual.
  • The as-needed record with four example lines, and the not given and other notes page with three lines for the R, A and O in the monthly record.
  • The who gives medications page filled in for three invented people: initials, full name, a handwritten signature, relationship or role, and a 555 phone number.
  • How it works: download two PDF files, type or write, print at home sideways, and initial each dose. Blank forms with no drug information and no advice; no physical item is shipped.

8 pictures: swipe to see them all, tap one to zoom.

What’s inside

8 pages in each PDF

  1. Start here: what's inside, how to print and fill in, and the codes1 page
  2. Monthly record, lines 1 to 12: medication and strength, time of day and a box for each day from 1 to 31, with name, date of birth, allergies and month and year at the top and the codes under the grid1 page
  3. Monthly record, continued: lines 13 to 241 page
  4. As-needed record: date, time, medication and strength, how much, reason given, initials and notes, 10 lines1 page
  5. Not given, and other notes: date, time, medication, code, what happened and initials, 11 lines1 page
  6. Who gives medications: initials, full name, signature, relationship or role and phone, 9 lines1 page
  7. Personal-use license and a note about the pages2 pages

$2.99printable PDF

Buy on Etsy
  • Instant download
  • 8 pages in each PDF
  • US Letter and A4
  • Fill-in fields need the free Adobe Acrobat Reader

Who it is for

Family members and helpers who share the job of giving one person their medications.

How it works

  1. Type before you print, in the free Adobe Acrobat Reader, or print the pages and write by hand. The name, date of birth, allergies and month fill in on every page they are on, and long names shrink to fit.
  2. Write each medication once for each time of day it is given, copying the name and strength from the pharmacy label.
  3. Whoever gives a dose writes their initials in that day's box. When a dose was not given, write R (refused), H (held), A (away) or O (other) and add a line on the notes page.
  4. Everyone who gives medications fills in one line on the who gives medications page.
  5. Print a new set for each month.

Sizes and format

  • 2 PDF files: US Letter (11 x 8.5 in) and A4, landscape, 8 pages each
  • Large print outside the 31-day grid: page titles 26 pt, labels 18 pt, column headings 14 to 16 pt
  • Day boxes 6 mm wide and 8.8 mm tall (about 1/4 by 1/3 inch), room for one set of initials; day numbers 12 pt
  • A long medication name typed into a fill-in field shrinks to fit its box
  • The fill-in fields need the free Adobe Acrobat Reader; the day boxes are for a pen
  • Blank forms, text and lines only: no pictures, no drug information, no doses, no advice
  • Instant download. No physical item is shipped.

The files

  • US LetterPDF, 8 pages, 247 KB
  • A4PDF, 8 pages, 247 KB

Your license

For personal use in one household: print as many copies as you need, and please don't share or resell the file.

A closer look

  • Cover: the Large-Print Medication Administration Record, with the monthly record filled in with five example medication lines and blue initials for October 1 to 11, in front of the as-needed record.
  • The five form pages in the file: the monthly record lines 1 to 12 and lines 13 to 24, the as-needed record, the not given and other notes page, and the who gives medications page.
  • The monthly record filled in: a long example name, date of birth, allergies and month at the top, five medication and time lines with invented medication names, and initials in the day boxes for days 1 to 11.
  • Close-up of the day boxes: initials from two people, one set in each day's box, and the letters R, A and O where a dose was not given as usual.
  • The as-needed record with four example lines, and the not given and other notes page with three lines for the R, A and O in the monthly record.
  • The who gives medications page filled in for three invented people: initials, full name, a handwritten signature, relationship or role, and a 555 phone number.
  • How it works: download two PDF files, type or write, print at home sideways, and initial each dose. Blank forms with no drug information and no advice; no physical item is shipped.

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Doctor Carissa is the shop of Carissa Spisak, who holds a doctorate in speech-language pathology.

An educational support tool. Not a substitute for evaluation or treatment by a licensed speech-language pathologist or physician. Read the full disclaimer.

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