OVER THE COUNTER (OTC)



OVER THE COUNTER (OTC)

MEDICATION RECORD

CHECK ONLY ONE BOX FOR EACH MEDICATION. ALL BLANKS MUST BE FILLED IN.

|(OTC) MEDICATION |CONDITION |YES |NO |

|Acetaminophen, Tylenol |Minor aches and pains | | |

|Aleve |Minor aches and pains | | |

|Aloe Vera Gel/Lotion |Sunburn | | |

|Ambesol |Toothache | | |

|Bactine |Cuts, abrasions, scratches | | |

|Benadryl, oral |Insect bites and stings | | |

|Benadryl, topical |Stings, bites, allergies | | |

|Betadine |Antiseptic | | |

|Caladryl/calamine lotion |Stings, bites, rashes | | |

|Capacol or generic throat lozenges |Sore throat | | |

|Chlorpheniramine-Chior-Trimetion |Allergies | | |

|Dimetapp, tablet or elixir |Colds, cough, allergies | | |

|Dramamine |Motion sickness | | |

|Gas-X |Gas | | |

|Hydrocortisone Cream – Cortaid |Itching | | |

|Hydrogen Peroxide |Antiseptic | | |

|Ibuprofen – Advil, Motrin |Minor aches, pains, cramps | | |

|Imodium A-D |Diarrhea | | |

|Kaopectate |Diarrhea | | |

|Midol |Menstrual cramps | | |

|Milk of Magnesia |Constipation | | |

|Neosporin |Minor scrapes, cuts | | |

|Mylanta |Upset stomach, gas | | |

|Pepto-Bismol |Upset stomach | | |

|Polysporin, or generic oint. |Minor scrapes, cuts | | |

|Robitussin Elixir |Colds, coughs | | |

|Sore throat spray-generic |Sore throat | | |

|Sudafed, tablets or elixir |Colds, allergies | | |

|Tenactin, Desenix or generic |Athlete’s foot | | |

|Tums |Indigestion, gas | | |

|Vicks Vaporub |Colds | | |

I give permission for my daughter ___________________________ to receive the following “Over the Counter” medications on an as needed basis. Unless otherwise directed, the medications will be administered as directed by package labeling.

______________________________ ______________

Parent or Guardian Signature Date

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