Over The Counter Medication Approval
Over The Counter Medication Approval
Patient name: _______________________________________________________
Please indicate by checking the space provided, if your patient may have on hand and use these medications for common ailments. Form expires one year from date of signature.
|Drug/Product |May Use |May Not |Description for Use |
| | |Use | |
|Acetaminophen | | |As directed on label for pain, headache, or fever |
|Ibuprofen | | |As directed on label for pain, headache, or fever |
|Naprosyn/Anaprox | | |As directed on label for pain, headache, or fever |
|May use the above for up to 3 consecutive days. Notify doctor if needed on day 4 |
|Pseudophedrine | | |As directed on label for sinus congestion |
|Allergy Capsules Diphenhydramine HCL | | |As directed on label for runny, itchy, nose, sneezing, scratchy throat, |
| | | |itchy/watery eyes |
|Antacid/Antiflatulent | | |As directed on label for indigestion, stomach upset, excess gas |
|Calcium Carbonate | | |As directed on label for heartburn |
|Do not use antacid within 1 hour of administering psychotropic medication |
|Anti-diarrhea | | |As directed on label after loose bowel movement |
|Cough syrup | | |AS directed on label for cough/congestion |
|Cough drops | | |As directed on label for cough |
|Ipecac syrup | | |As directed on label |
|Calamine lotion | | |As directed on label for poison ivy, poison oak, poison sumac |
|Anti-Itch cream/spray | | |Apply to affected area as directed on label, do not use on broken skin |
|Desenex powder | | |As directed on label fro Athlete’s foot |
|Sunscreen lotion | | |As directed on label before exposure to sunlight |
|Sunburn lotion/cream | | |As directed on label for sunburn |
|Hydrogen Peroxide | | |As directed on label for cuts, scrapes |
|First Aid spray | | |As directed on label for cuts, scrapes |
|Triple Antibiotic ointment | | |As directed on label for cuts or scrapes and cover with dry sterile |
| | | |dressing if needed. Notify Dr of redness or swelling |
|Warm/Cold Packs | | |Apply to affected/painful areas as needed |
|Fluoride Rinse | | |As directed on label |
|Stool Softener | | |As directed on label if no bowel movement in ___days |
|Laxative | | |As directed on label, if no bowel movement in ___days |
|Milk of Magnesia | | |As directed on label, if no bowel movement in ___ days |
|Dandruff shampoo | | |As directed on label |
| | | | |
| | | | |
| | | | |
Physician’s Signature Date
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