Prescribing Physician: _________________________________________
Medications: _______________ Rx: No Yes Number(s): ______ Dosage:
___________________________ Date filled: _______________ Route:
P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily
B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle:
_______________ Comments: ___________________
Prescribing Physician: _________________________________________
Medications: _______________ Rx: No Yes Number(s): ______ Dosage:
___________________________ Date filled: _______________ Route:
P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily
B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle:
_______________ Comments: ___________________
Prescribing Physician: _________________________________________
Medications: _______________ Rx: No Yes Number(s): ______ Dosage:
___________________________ Date filled: _______________ Route:
P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily
B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle:
_______________ Comments: ___________________
Prescribing Physician: _________________________________________
Medications: _______________ Rx: No Yes Number(s): ______ Dosage:
___________________________ Date filled: _______________ Route:
P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily
B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle:
_______________ Comments: ___________________
Prescribing Physician: _________________________________________
Medications: _______________ Rx: No Yes Number(s): ______ Dosage:
___________________________ Date filled: _______________ Route:
P.O. I.M. S.C. S.L. Topical Inhalation Rectal Times: PRN Daily
B.I.D. T.I.D. Q.I.D. A.C. P.C. H.S. Amount in bottle:
_______________ Comments: ___________________
Med Time S M T W T F S
Med Time S M T W T F S
Med Time S M T W T F S
Med Time S M T W T F S
Med Time S M T W T F S
Initi
al
Si
gnat
ure
Nam
e
Po
sitio
n __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
IN
STR
UC
TIO
NS:
She
et is
for r
epro
duct
ion
as n
eede
d. I
t sho
uld
be th
ree-
hole
pun
ched
and
kep
t in
a bi
nder
dur
ing
cam
p w
eek.
Use
one
sh
eet f
or e
ach
cam
per w
ith a
pre
scrip
tion.
Rec
ord
all m
edic
ines
bro
ught
to c
amp
(up
to F
IVE
med
icat
ions
per
shee
t). T
he m
edic
atio
n,
dosa
ge a
nd d
osag
e sc
hedu
le sh
ould
be
copi
ed fr
om th
e pr
escr
iptio
n. R
ecor
d di
spen
sing
tim
es a
nd d
ays i
n th
e bl
ocks
pro
vide
d fo
r eac
h m
edic
atio
n as
they
are
dis
pens
ed.
Afte
r cam
p, p
lace
shee
t(s) i
nsid
e th
e fir
st a
id lo
g.
P.O. = by mouth I.M. = intermuscular S.C. = sub-cutaneous S.L. =
sub-lingual-under-tongue PRN = as needed B.I.D. = two times a day
T.I.D. = three times a day Q.I.D. = four times a day A.C. = before
meals P.C. = after meals H.S. = hours of sleep (taken at
bedtime)
Rou
tine
Dru
g A
dmin
istr
atio
n R
ecor
d
Nam
e: _
____
____
____
____
____
____
____
____
____
____
____
Cam
psite
: ___
____
____
____
____
____
____
____
Tr
oop
No.
: ___
____
____
____
___
Dat
e of
birt
h: _
____
____
____
__ C
lass
ifica
tion:
___
____
____
____
____
____
D
rug
hype
rsen
sitiv
ity: _
____
____
____
____
____
____
____
____
____
____
____
____
___
Wei
ght:
____
____
____
_
/ColorImageDict > /JPEG2000ColorACSImageDict >
/JPEG2000ColorImageDict > /AntiAliasGrayImages false
/CropGrayImages true /GrayImageMinResolution 300
/GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true
/GrayImageDownsampleType /Bicubic /GrayImageResolution 300
/GrayImageDepth -1 /GrayImageMinDownsampleDepth 2
/GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true
/GrayImageFilter /DCTEncode /AutoFilterGrayImages true
/GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict >
/GrayImageDict > /JPEG2000GrayACSImageDict >
/JPEG2000GrayImageDict > /AntiAliasMonoImages false
/CropMonoImages true /MonoImageMinResolution 1200
/MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true
/MonoImageDownsampleType /Bicubic /MonoImageResolution 1200
/MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000
/EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode
/MonoImageDict > /AllowPSXObjects false /CheckCompliance [ /None
] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false
/PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000
0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true
/PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ]
/PDFXOutputIntentProfile () /PDFXOutputConditionIdentifier ()
/PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped
/False
/CreateJDFFile false /Description > /Namespace [ (Adobe)
(Common) (1.0) ] /OtherNamespaces [ > /FormElements false
/GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks
false /IncludeInteractive false /IncludeLayers false
/IncludeProfiles false /MultimediaHandling /UseObjectSettings
/Namespace [ (Adobe) (CreativeSuite) (2.0) ]
/PDFXOutputIntentProfileSelector /DocumentCMYK /PreserveEditing
true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling
/UseDocumentProfile /UseDocumentBleed false >> ]>>
setdistillerparams> setpagedevice
Prescribing Physician: Medications: Numbers: Dosage: Date
filled: Med TimeRow1: SRow1: MRow1: TRow1: WRow1: TRow1_2: FRow1:
SRow1_2: Med TimeRow2: SRow2: MRow2: TRow2: WRow2: TRow2_2: FRow2:
SRow2_2: Med TimeRow3: SRow3: MRow3: TRow3: WRow3: TRow3_2: FRow3:
SRow3_2: Amount in bottle: Comments: Med TimeRow4: SRow4: MRow4:
TRow4: WRow4: TRow4_2: FRow4: SRow4_2: Prescribing Physician_2:
Medications_2: Numbers_2: Dosage_2: Date filled_2: Med TimeRow1_2:
SRow1_3: MRow1_2: TRow1_3: WRow1_2: TRow1_4: FRow1_2: SRow1_4: Med
TimeRow2_2: SRow2_3: MRow2_2: TRow2_3: WRow2_2: TRow2_4: FRow2_2:
SRow2_4: Med TimeRow3_2: SRow3_3: MRow3_2: TRow3_3: WRow3_2:
TRow3_4: FRow3_2: SRow3_4: Amount in bottle_2: Comments_2: Med
TimeRow4_2: SRow4_3: MRow4_2: TRow4_3: WRow4_2: TRow4_4: FRow4_2:
SRow4_4: Prescribing Physician_3: Medications_3: Numbers_3:
Dosage_3: Date filled_3: Med TimeRow1_3: SRow1_5: MRow1_3: TRow1_5:
WRow1_3: TRow1_6: FRow1_3: SRow1_6: Med TimeRow2_3: SRow2_5:
MRow2_3: TRow2_5: WRow2_3: TRow2_6: FRow2_3: SRow2_6: Med
TimeRow3_3: SRow3_5: MRow3_3: TRow3_5: WRow3_3: TRow3_6: FRow3_3:
SRow3_6: Amount in bottle_3: Comments_3: Prescribing Physician_4:
Med TimeRow4_3: SRow4_5: MRow4_3: TRow4_5: WRow4_3: TRow4_6:
FRow4_3: SRow4_6: Medications_4: Numbers_4: Dosage_4: Date
filled_4: Med TimeRow1_4: SRow1_7: MRow1_4: TRow1_7: WRow1_4:
TRow1_8: FRow1_4: SRow1_8: Med TimeRow2_4: SRow2_7: MRow2_4:
TRow2_7: WRow2_4: TRow2_8: FRow2_4: SRow2_8: Amount in bottle_4:
Comments_4: Med TimeRow3_4: SRow3_7: MRow3_4: TRow3_7: WRow3_4:
TRow3_8: FRow3_4: SRow3_8: Prescribing Physician_5: Med TimeRow4_4:
SRow4_7: MRow4_4: TRow4_7: WRow4_4: TRow4_8: FRow4_4: SRow4_8:
Medications_5: Numbers_5: Dosage_5: Date filled_5: Med TimeRow1_5:
SRow1_9: MRow1_5: TRow1_9: WRow1_5: TRow1_10: FRow1_5: SRow1_10:
Med TimeRow2_5: SRow2_9: MRow2_5: TRow2_9: WRow2_5: TRow2_10:
FRow2_5: SRow2_10: Med TimeRow3_5: SRow3_9: MRow3_5: TRow3_9:
WRow3_5: TRow3_10: FRow3_5: SRow3_10: Med TimeRow4_5: SRow4_9:
MRow4_5: TRow4_9: WRow4_5: TRow4_10: FRow4_5: SRow4_10: Amount in
bottle_5: Comments_5: No1: OffYes1: OffNo2: OffYes2: OffNo3:
OffYes3: OffNo4: OffYes4: OffNo5: OffYes5: OffCheckBoxSC:
OffCheckBoxSL: OffCheckBoxInhale: OffCheckBoxBID: OffCheckBoxQID:
OffCheckBoxTopical: OffCheckBoxRectal: OffCheckBoxPRN:
OffCheckBoxDaily: OffCheckBoxTID: OffCheckBoxAC: OffCheckBoxPC:
OffCheckBoxHS: OffCheckBoxIM: OffCheckBoxPO: OffCheckBoxPO2:
OffCheckBoxIM2: OffCheckBoxSC2: OffCheckBoxSL2:
OffCheckBoxTopical2: OffCheckBoxInhale2: OffCheckBoxRectal2:
OffCheckBoxQID2: OffCheckBoxDaily2: OffCheckBoxBID2:
OffCheckBoxTID2: OffCheckBoxAC2: OffCheckBoxPC2: OffCheckBoxPRN2:
OffCheckBoxHS2: OffCheckBoxPO3: OffCheckBoxIM3: OffCheckBoxSC3:
OffCheckBoxSL3: OffCheckBoxTopical3: OffCheckBoxInhale3:
OffCheckBoxRectal3: OffCheckBoxAC3: OffCheckBoxPC3:
OffCheckBoxPRN3: OffCheckBoxDaily3: OffCheckBoxBID3:
OffCheckBoxTID3: OffCheckBoxQID3: OffCheckBoxHS3:
OffCheckBoxTopical4: OffCheckBoxInhale4: OffCheckBoxRectal4:
OffCheckBoxPO4: OffCheckBoxIM4: OffCheckBoxSC4: OffCheckBoxSL4:
OffCheckBoxQID4: OffCheckBoxDaily4: OffCheckBoxBID4:
OffCheckBoxTID4: OffCheckBoxPRN4: OffCheckBoxAC4: OffCheckBoxPC4:
OffCheckBoxHS4: OffCheckBoxPO5: OffCheckBoxIM5: OffCheckBoxSC5:
OffCheckBoxSL5: OffCheckBoxTopical5: OffCheckBoxInhale5:
OffCheckBoxRectal5: OffCheckBoxPRN5: OffCheckBoxDaily5:
OffCheckBoxBID5: OffCheckBoxTID5: OffCheckBoxQID5: OffCheckBoxAC5:
OffCheckBoxPC5: OffCheckBoxHS5: OffName: Campsite: TroopNo:
DateofBirth: Classification: DrugHypersensitivity: Weight:
Signature1: Signature2:
