Post-Op Medication Log: A Free Printable Template for Patients

By Blake Hickey, Double Jaw Marketing, Jupiter, Florida. For practice owners and office managers. Updated October 17, 2026.

A post-op medication log is a sheet where a patient writes down every dose they take after a procedure: the medication, the dose as prescribed, the time they took it and when the next one is due. Below is a free, blank one your practice can print and hand out. It works for oral surgery, orthodontic and dental procedures.

Patients can go home with more than one medication, each on its own schedule. A paper log gives them one place to write it all down. It helps your office too. When a patient calls with a question, your team can ask them to read from the log: what they took, when, and how their pain and swelling are going. That beats guessing from memory.

The idea isn't new. The FDA offers a form called My Medicine Record to help people keep track of their medicines, and suggests sharing it with doctors and pharmacists at every visit. This log is built for the first days after a procedure.

What goes in a post‑op medication log?

• My medications: each one and the dose as prescribed, copied from the label.
• Dose log, 22 rows: date, time taken, medication, dose, a Taken box, next dose due, pain 0 to 10 and notes.
• Daily recovery tracker: ice, liquids and foods, swelling, sleep and pain for seven days.
• All on two pages, so it prints on one sheet of paper, front and back.
• Questions for the next visit, with your office and after-hours numbers right on the page.

Free printable post‑op medication log

Swap in your [Practice name], [Phone] and [After-hours line], then print a stack for the front desk. No medication names or doses are filled in. Your doctor's instructions stay the source for those.

[Your logo here]
**[Practice name]** | [Phone] | [Website]

# After-surgery medication log

One place to write down every dose. Office: [Phone]. After hours: [After-hours line].

> Follow your doctor's instructions. This log does not replace them. Call the office with questions; in an emergency call 911.

Patient name: ______________________
Procedure: ______________________
Procedure date: ______________________
Next visit: ______________________

## My medications (copy each one from the label)

| Medication | Dose as prescribed | How often | Start date | Notes |
|---|---|---|---|---|
|   |   |   |   |   |
|   |   |   |   |   |
|   |   |   |   |   |
|   |   |   |   |   |
|   |   |   |   |   |

## How to fill it in

1. Copy each medication and its dose from the prescription label or your discharge sheet.
2. Each time you take a dose, write the date and time and check the Taken box.
3. Write when the next dose is due, from your instructions.
4. Keep this log by the phone when you call the office, and bring it to your next visit.

## Dose log: one row for every dose

| Date | Time taken | Medication | Dose | Taken | Next dose due | Pain 0 to 10 | Notes |
|---|---|---|---|---|---|---|---|
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |

---

## Dose log, continued

| Date | Time taken | Medication | Dose | Taken | Next dose due | Pain 0 to 10 | Notes |
|---|---|---|---|---|---|---|---|
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |
|   |   |   |   | [ ] |   |   |   |

## Daily recovery tracker: fill in one column each evening

|  | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Day 6 | Day 7 |
|---|---|---|---|---|---|---|---|
| Date |   |   |   |   |   |   |   |
| Ice or cold packs (times) |   |   |   |   |   |   |   |
| Liquids and foods |   |   |   |   |   |   |   |
| Swelling (less, same, more) |   |   |   |   |   |   |   |
| Sleep (hours) |   |   |   |   |   |   |   |
| Pain at its worst (0 to 10) |   |   |   |   |   |   |   |

## Questions for my next visit

- ______________________________
- ______________________________
- ______________________________

> Follow your doctor's instructions. Questions? Call [Practice name] at [Phone]. After hours: [After-hours line]. In an emergency call 911.

---
Template from Double Jaw Marketing, doublejawmarketing.com/resources. Practices may copy and adapt it. Have your doctor review it before you hand it out.

How should a practice hand out the log?

1. In the consult kit. Put a copy in the folder patients take home from the surgical consult, so they've seen it before the procedure day.
2. At discharge. Hand it over with the prescriptions and go through the My medications box together, or fill it in for the patient from the discharge sheet.
3. Emailed as a PDF. Attach the blank PDF to your post-op email or text so patients can print another copy at home.

A blank form has no patient information on it, so emailing it is simple. HHS says HIPAA lets providers communicate with patients by email with reasonable safeguards, such as checking the address first. Once a patient fills the log in, it holds health details, so ask them to bring it to the visit or send it through your patient portal instead of replying by email.

What should you check before you hand it out?

The log is for writing things down. It isn't the place for medical directions, so keep your post-op instructions on their own sheet. Run through this list once before the first batch.

Common questions

What should a post-op medication log include?

The medication and the dose as prescribed, the date and time each dose was taken, a box to check when it's taken, when the next dose is due, a pain score from 0 to 10 and room for notes. This one adds a daily tracker for ice, liquids, swelling and sleep, and a place for questions for the next visit.

Can our practice give this log to patients?

Yes. It's free to copy and adapt. Add your practice name and phone numbers, and have your doctor review it before you hand it out. It's a blank form, and your doctor's instructions still come first.

Should the log list the patient's medications?

Not on the version you print in bulk. Leave it blank so it works for any procedure, and have the patient or your team copy each medication and dose from the prescription label or discharge sheet.

Can we email the log to patients?

Yes. A blank form has no patient information on it. Once a patient fills it in, it holds health details, so ask them to bring it to the next visit or send it through your patient portal instead of replying by email.

Sources

Checked October 17, 2026. Rules and platform limits change, so check the source before you rely on it.

1. FDA: My Medicine Record
2. HHS FAQ 570: Does HIPAA permit health care providers to use e-mail to discuss health issues with patients?