Medication Log Template
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1MEDICATION LOG
Taken from information provided by physician on the Request for Medication to be Given During School Hours Form.
Name of Student: _________________________________________________________
School: _________________________________________________________________
Medication: _____________________________________________________________
(each medication is to be listed on a separate form)
Dosage/Route: _____________________ Prescription Dates: __________ to ________
Time(s) medication is to be given a.m. ______________ p.m. ______________
Special Instructions: _______________________________________________________
________________________________________________________________________
(e.g., purpose of medication, side effects, any special instructions for giving meds)
DAY
TIME
DOSE
SIGNATURE
am
Wednesday
lunch
pm
other
am
Thursday
lunch
pm
other
Friday
am
lunch
pm
other
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Parent category: Medical