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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: _
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Cam
psite
: ___
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____
____
Tr
oop
No.
: ___
____
____
____
___
Dat
e of
birt
h: _
____
____
____
__ C
lass
ifica
tion:
___
____
____
____
____
____
D
rug
hype
rsen
sitiv
ity: _
____
____
____
____
____
____
____
____
____
____
____
____
___
Wei
ght:
____
____
____
_