Over The Counter Medication Form
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1OVER THE COUNTER MEDICATION FORM
Client/Patient Name: _____________________________________ DOB: ______________
STANDING ORDERS FOR OVER THE COUNTER MEDICATIONS
MEDICATION
TREATMENT GOALS
STRENGTH
Allergy and Cold Preparations
For relief of allergy or cold symptoms
As dispensed OTC
Kaopectate concentrate or
For relief of loose bowel movements
As dispensed OTC
Generic
Milk of Magnesia or Generic
For relief of Constipation
As dispensed OTC
For relief of minor aches & pains, and
Tylenol or Generic
As dispensed OTC
/or fever
For relief of minor aches & pains, and
Ibuprofen or Generic
As dispensed OTC
/or fever
Benadryl or Generic.
For relief of allergy symptoms
As dispensed OTC
Multivitamin and Nutrition
Food Supplement
As dispensed OTC
Supplements
Cough and Cold preparation
For relief of cold and cough symptoms
As dispensed OTC
Comments:
Read Carefully:
By my signature below, I acknowledge that during my participation in the First at Blue Ridge, Inc. residential
treatment program, I will take only take those over-the-counter medications listed above. Further, I agree only to
take recommended doses and for the indicated uses on the over-the-counter medication packages. I recognize that
it is my responsibility to review the package information, with each dose taken, for any potential adverse
interactions and contraindications to my use. Further, I hereby agree to hold First at Blue Ridge Inc., and the
healthcare provider listed below harmless if I take any over the counter medication not listed above or outside
the parameters of recommended dosages, uses and warnings or contraindications.
_____________________________________ ____________________________ Date ______________________
Physician Signature
Physician Print
Client’s signature ____________________________________________________ Date ______________________
Even if not on prescription medications ALL forms must be signed.
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