me - · pdf fileprescribing physician: _____ medications: _____ __ _____ rx: no yes...

Prescribing Physician: _________________________________________ Medications: _______________ Rx: No Yes Number(s): ______ Dosage: ___________________________ Date filled: _______________ Route: P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle: _______________ Comments: ___________________

Prescribing Physician: _________________________________________ Medications: _______________ Rx: No Yes Number(s): ______ Dosage: ___________________________ Date filled: _______________ Route: P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle: _______________ Comments: ___________________

Prescribing Physician: _________________________________________ Medications: _______________ Rx: No Yes Number(s): ______ Dosage: ___________________________ Date filled: _______________ Route: P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle: _______________ Comments: ___________________

Prescribing Physician: _________________________________________ Medications: _______________ Rx: No Yes Number(s): ______ Dosage: ___________________________ Date filled: _______________ Route: P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle: _______________ Comments: ___________________

Prescribing Physician: _________________________________________ Medications: _______________ Rx: No Yes Number(s): ______ Dosage: ___________________________ Date filled: _______________ Route: P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle: _______________ Comments: ___________________

Med Time S M T W T F S

Med Time S M T W T F S

Med Time S M T W T F S

Med Time S M T W T F S

Med Time S M T W T F S

Initi

al

Si

gnat

ure

Nam

e

Po

sitio

n __

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IN

STR

UC

TIO

NS:

She

et is

for r

epro

duct

ion

as n

eede

d. I

t sho

uld

be th

ree-

hole

pun

ched

and

kep

t in

a bi

nder

dur

ing

cam

p w

eek.

Use

one

sh

eet f

or e

ach

cam

per w

ith a

pre

scrip

tion.

Rec

ord

all m

edic

ines

bro

ught

to c

amp

(up

to F

IVE

med

icat

ions

per

shee

t). T

he m

edic

atio

n,

dosa

ge a

nd d

osag

e sc

hedu

le sh

ould

be

copi

ed fr

om th

e pr

escr

iptio

n. R

ecor

d di

spen

sing

tim

es a

nd d

ays i

n th

e bl

ocks

pro

vide

d fo

r eac

h m

edic

atio

n as

they

are

dis

pens

ed.

Afte

r cam

p, p

lace

shee

t(s) i

nsid

e th

e fir

st a

id lo

g.

P.O. = by mouth I.M. = intermuscular S.C. = sub-cutaneous S.L. = sub-lingual-under-tongue PRN = as needed B.I.D. = two times a day T.I.D. = three times a day Q.I.D. = four times a day A.C. = before meals P.C. = after meals H.S. = hours of sleep (taken at bedtime)

Rou

tine

Dru

g A

dmin

istr

atio

n R

ecor

d

Nam

e: _

____

____

____

____

____

____

____

____

____

____

____

Cam

psite

: ___

____

____

____

____

____

____

____

Tr

oop

No.

: ___

____

____

____

___

Dat

e of

birt

h: _

____

____

____

__ C

lass

ifica

tion:

___

____

____

____

____

____

D

rug

hype

rsen

sitiv

ity: _

____

____

____

____

____

____

____

____

____

____

____

____

___

Wei

ght:

____

____

____

_