---
title: Medication administration record for home: free printable
url: https://dose-log-kokkeong.web.app/medication-administration-record
description: A free printable medication record for home: a month grid with a box for every dose, to initial when it's given, so everyone who helps can see what's done.
---

Free to print

# Medication record for home use

When more than one person helps with someone's medicines, a shared record stops doses being given twice or not at all. Write in each medicine and time, then initial the box when a dose is given.

## How to use it

1. Copy each medicine, its strength and dose, and the time from the label or the pharmacy's instructions. One line per time: a medicine taken morning and evening gets two lines.
2. When a dose is given, write your initials in that day's box.
3. Write **S** if it was skipped and **R** if it was refused, and add a note on the back with why.
4. Keep the record with the medicines, and start a new month on a new sheet.

## Days 1 to 16

Month: ______________ · Name: ______________ · Days 1–16

| Medicine and dose | Time | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

## Days 17 to 31

Month: ______________ · Name: ______________ · Days 17–31

| Medicine and dose | Time | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

## Who gave it

People who give medicines

| Initials | Name | Phone |
|---|---|---|

## Keeping it useful

- Change the record only when the prescription or the pharmacy's instructions change, and date the change.
- Bring it to appointments and medication reviews: it shows what was given, not what was meant to be.
- Ask the doctor or pharmacist about anything you're not sure of. This record doesn't tell anyone what to give.

Also free: a [medicine list](https://dose-log-kokkeong.web.app/medication-list) and a [wallet medicine card](https://dose-log-kokkeong.web.app/wallet-medication-card) for the person you look after.

## Share the record without the paper

Dose Log keeps a list for each person you look after, reminds you at each time, and keeps every dose as Taken, Skipped or Not logged. You and one more person are free.

[Download on the App Store](https://apps.apple.com/app/id6829500440?ct=blog_tool_medication-administration-record)

This page helps you keep track; it isn't medical advice. Ask your doctor or pharmacist about your own medicines. Reviewed 5 November 2026.