Constipation Medicine Guardian

By | September 21, 2016

Constipation Drowsiness or excitability Stomach upset Alert: Students with temperature over 100.4 must be sent home INSTRUCTIONS: Each of the three sections must be completed by parent/guardian for student to receive an over-the-counter (OTC),

HEALTH HISTORY and MEDICAL INFORMATION Constipation Convulsions The camp has a supply of non-asprin pain relievers, cough medicine, decongestants, antacids, and first-aid ointments which will be

Parent/Guardian Authorization for Health Care This health history is correct and accurately reflects the health status of the camper to whom it pertains.

CAMPER HEALTH HISTORY FORM 1 Mail by_____ _____ Food _____ Medicine _____ Environment ( Insects, Hay Laxatives for constipation (Ex-Lax) Guaifenesin cough syrup (Robitussin) Dextromethorphan cough syrup (Robitussin DM)

Medicines to Treat Cough & Cold 23 March 2012 Generic name • Constipation • Urinary retention May cause drowsiness Pharmacy only Bromhexine 8 mg tablet Bromhexine 4 mg/5 ml Elixir Cough & Cold Medicine List

Additional contact in event parent(s)/guardian(s) can Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin) Laxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)

Mother/Guardian Work Phone Father/Guardian Work Phone Pediatrician/Primary Care Doctor PCP Phone A. Past Medical History 1. Constipation Lumps/growths Hallucinations Soiling underpants Paranoia Diarrhea Genital/Urinary System Phobia

Camp Downer Health Statement and Parent/Guardian Approval Form (Sudafed), Diphenhydramine antihistamine/allergy medicine (Benadryl), Dextromethorphan cough syrup Calamine lotion, Aloe, Laxatives for constipation (Ex-Lax), Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)

Student Health Information (ADD/ADHD, constipation, migraines, allergies, This medicine is furnished by parent or guardian in the original labeled container, including date, name and strength of the medicine and directions for use.

Page 1 2016 Camp Osito Rancho Health History and Medical Examination Form Please type or write clearly and legibly. Parent/Guardian Directions:

Parent/Guardian _____Date: to Camper This camper is allergic to: Food Medicine The environment (insect stings, hay fever Have problems with diarrhea/constipation?………………. Yes No 9. Had headaches

Signature of Parent/Guardian: Date: Contact Information Parent or Medicine The Environment (insect stings, hay fever, etc.) Other (describe below) Vaccine Month/Year Month Generic Cough Drops Laxatives for constipation (Ex-Lax) Page 3 of 4. To Parent(s

Youth Emergency/Medical Information Form _____ Camper Information: Camper Name: Parent/Guardian with legal custody to be contacted in case of illness or injury: Upset Stomach Yes Constipation Yes Bed Wetting Yes

Parent/guardian with legal custody to be contacted in case of illness or injury: Laxatives for constipation (Ex-Lax) Calamine lotion Antibiotic cream Medications Being Taken: Health Form 2013

For Elder's admission to Acute hospital care A-D-C A V-A-N-D-I-M-L-S mnemonic (adapted) (tele? etc) if patient not capable of medical decisions alert POA or Guardian D-iagnosis: List: primary diagnosis Constipation? eliminate unnecessary meds

Past Medical History Current Medications & Dosages Rashes Constipation Bone pain/fracture FAMILY MEDICINE ASSOCIATES OF TEXAS, P.A. 4333 N. Josey Lane, Plaza II, Suite 302 Carrollton, Texas 75010

Medicines to Treat Cough & Cold 23 March 2012 Generic name • Constipation • Urinary retention May cause drowsiness Pharmacy only Bromhexine 8 mg tablet Bromhexine 4 mg/5 ml Elixir Cough & Cold Medicine List

Parent/Guardian Consent for Medication Administration (Page 1 of 2) information relative to the prescribed medicine administration as s/he dry mouth, constipation, anorexia, leukopenia, dyspnea, skin rash, flulike syndrome. Onset/Peak/Duration: O: Unknown P: 1 1/2 hrs D: Unknown

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF MEDICINE DEPARTMENT OF FAMILY MEDICINE Patient: _____ CONTROLLED SUBSTANCES CONTRACT I. POLICIES AND STATEMENTS A. Purpose The purpose of this agreement is to protect your access to Constipation. This is very common,

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