Medication and Emergency Information
|Medication/Emergency Contact Information |Name | | |
| | | | |
| |ID Number | | |
| | | | |
|Name/Credentials of Staff Initially Completing the form: | |
|Date Initially Completed: | |
| |
|CURRENT MEDICATIONS |
|List ALL known and/or reported medications the individual is currently taking regardless of type or purpose to include over-the-counter (OTC) medications (use |
|additional pages, if needed): |
|Staff Signature/ |Date Initiated|Name of Medication |Prescribed by |Dosage/ |Date Terminated/ |Staff Signature/ |
|Credential | | | |Frequency |Changed |Credential |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
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|Known Allergies/Reactions: |
| |
|PREVIOUS MEDICATIONS |
|Medication |Directions |Comments |
| | |(to include adverse reactions if applicable) |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| |
|Special Dietary Needs (if applicable): |
| |
| |
| |
|Emergency Information: |
|In case of emergency (when parent/legal representative cannot be reached) contact: |
|Name: | |
|Phone Number: |(primary) | |(secondary) | |
|Address: | |
|Primary Doctor: | |
|Doctor’s Phone: | |
|Doctor’s Address: | |
|Hospital Preference: | |
|Insurance Carrier(s): | |
|Policy Number(s): | |
| | |
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