APPENDIX 1



2219325-51054000 Appendix 1CONSENT FORM FOR COMMONLY USED HOMELY REMEDIESName of Child/Young Person:- (DOB:-)MedicationIndicationChild DoseMaximum Daily DoseContra-indications, Special PrecautionsParacetamol tablets500 mgMild to moderate pain including period painOver 12 years1 to 2 tablets(500 - 1,000 mg) every 4 to 6 hours4 doses (2,000 - 4,000 mg) in 24 hoursCaution in renal/kidney conditions risk of liver damage if maximum dose is exceeded.Side effects are rare but possible rashes, blood disorders and acute pancreatitis.Calpol 6 PlusMeltlets 250 mg(Paracetamol)Mild to moderate painChild over 6 years1 or 2 tablets (250 - 500 mg) every 4 to 6 hoursTablets to be dissolved in the mouth or can be mixed in a little milk or water4 doses (1,000 - 2,000 mg)in 24 hoursCaution in renal/kidney conditions risk of liver damage if maximum dose is exceeded.Side effects are rare but possible rashes, blood disorders and acute pancreatitis.Kwells/Joy RidesMotion sicknessChild 4 - 10 years75 - 150 micrograms They can be taken 20 - 30 minutes before travelling or at the onset of sicknessChild over 10 years 150 - 300 microgramsThey can be taken 20 - 30 minutes before travelling or at the onset of sickness3 doses in 24 hoursPossible side effects include drowsiness, dry mouth, dizziness, blurred vision, difficulty in micturition.Consent Form for Commonly Used Homely Remedies MedicationIndicationChild DoseMaximum Daily DoseContra-indications, Special PrecautionsBonjela Teething GelMild oral lesionsFrom 2 months - 16 yearsMassage a small amount of Bonjela gel on to the sore areaThis can be repeated every 3 hoursNo more than 6 applications in 24 hoursNone applicable to children.Simple linctus (paediatric)Dry or painful cough6 - 12 years 5 - 10 ml3 doses in 24 hoursCaution in asthma, renal impairment.Possible side effects include constipation.Kalms – herbal remedyInsomniaOver 12 years2 tablets3 doses in 24 hoursAllergy to ingredientsSudocremPressure sores, rashesNoneNoneNoneVaseline/LypsylSore and chapped lipsUse frequentlyNo limitAllergy to ingredients.E45 creamDry skin and minor irritationsAs necessaryNo limitAllergy to ingredients.Consent Form for Commonly Used Homely RemediesName of Child/Young Person:- (DOB:-)MedicationIndicationChild DoseMaximum Daily DoseContra-indications, Special PrecautionsStrepsilsLocketsSoothersMinor sore throats and dry coughsDissolve 1 Strepsil lozenge slowly in the mouth every 2 to 3 hoursConsent Form for Commonly Used Homely RemediesThe above medications are the only medications which may be administered without prescription. They may be administered for a maximum of 2 days with the exception of Lypsyl/Vaseline. If symptoms persist a consultation with Xxx’s General Practitioner is required.AuthorisationI authorise Xx, Registered Manager of Xx, or a delegated member of staff to administer the above medication to Xx if required.Signed:-……………………………………………………………………Name:-……………………………………………..Position:-……………………………………………………………………Date:-…………………………………………….. ................
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