Download MARIST COLLEGE UPWARD BOUND - INDIVIDUALIZED ORDER FORM 3399 NORTH ROAD

MARIST COLLEGE UPWARD BOUND - INDIVIDUALIZED ORDER FORM
3399 NORTH ROAD
POUGHKEEPSIE, NY 12601 TEL: 845-575-3258 FAX: 845-575-3259
INDIVIDUALIZED ORDERS FOR
Name: ____________________________________________________
DOB: _______________________
Weight: ________________
The following form must be completed and signed by the child’s physician. If the child will be taking any prescription
medication while at camp, the doctor must also complete the reverse side of this form. Camp nurses are only
permitted to dispense medications to a child that is listed on this form by the child’s doctor.
The Camp Nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the camper and/or the
camper’s medication(s).
Standard Over the Counter/PRN Medications (the following medications are available in the Infirmary and will be administered at the
discretion of a RN, if approval is indicated by the camper’s healthcare provider):
Drug Name
Tylenol (or generic)
Ibuprofen
Robitussin (or
generic)
Pepto-Bismol (or
generic)
Kaopectate (or
generic)
Children’s Mylanta
(or generic)
Route
PO (Chewable,
elixir, or tabs) PR
(suppository)
PO (Chewable
tabs, suspension,
or tabs)
PO (Syrup)
PO (Liquid, or
chewable tabs)
PO (Liquid or tabs)
PO (Chewable
tabs)
Sudafed (or
generic)
PO (Tabs/liquid)
Chlorpheniramine
PO (Chewable
tabs, suspension,
or tabs)
PO (Chewable,
regular tabs)
Dramamine/Bonine
(or generic)
Dimetapp (or
generic)
PO (Elixir or tabs)
Benadryl (or
generic)
PO/Topical
(Elixir, chewable
tabs or pills)
(Topical ointment)
Dosage
Indications
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Per label
instructions by
age/weight
Pain or fever
Health
Care
Provider
Order
Yes
No
Pain or fever
Yes
No
Cough
Yes
No
Upset stomach,
diarrhea
Yes
No
Diarrhea
Yes
No
Upset stomach
Yes
No
Nasal congestion,
Eustachian tube
congestion
Seasonal allergy
symptoms
Yes
No
Yes
No
Motion sickness
Yes
No
Nasal congestion,
seasonal allergy
symptoms
Allergic reactions,
(hives, insect bites)
Yes
No
Yes
No
Comments
(continue on other side)
Antibiotic
Ointment
Hydrocortisone
Cream
Topical
Calamine Lotion (or
generic)
Mentholyptic
Cough Lozenges
Topical
Per label
instructions
Per label
instructions
Topical
Per label
instructions
Per label
instructions
Superficial
cuts/abrasions
Allergic reactions
(contact
dermatitis, insect
bites)
Allergic reactions,
(hives, insect bites)
Coughing, sore
throat
Yes
No
Yes
No
Yes
No
Yes
No
Prescription Medications (Please complete with the patient’s current regimen for both scheduled and PRN medications):
Drug Name
Route
Dosage and
Schedule
Indications
Camper
Health Care
Provider
Order
Comments
Additional Orders: (As deemed necessary by health care provider to be implemented by a RN)
______________________________________________________________________________________________________________________
_________________________________________________________________________________________________
Camper’s Health Care Provider Name: __________________________________
Phone #: ________________
Type/Print Name: _________________________________________________________________________________
Address: __________________________________________________________
License#: ___________________
Signature: _________________________________________________________
Date: ______________________