Individual Medications Required Addendum To The Bsa Annual Health And Medical Record Form

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Required addendum to the BSA Annual Health and Medical Record (must be updated yearly).
Individual Medications Order for Standard Over the Counter /PRN and Prescription Medications:
Scout’s Name: _____________________________
Unit: ______________
Do not give over the counter medicine
The following medications are available at the Camp Health Lodge and will be administered at the discretion of our Health
Officer if the Camper’s health care provider notes the approval. The Camp Health Officer will not be able to medicate
campers without prior approval as indicated on this form.
Drug Name
Administration
Dosage
Schedule and
Camper
Comments
route
Indications
HealthCare
Provider Order
Tylenol
Per label
Per label
Q 4 hr prn for pain or fever
Yes
No
Ibuprofen
Per label
Per label
Q 6 hr prn for pain or fever
Yes
No
Benadryl
Per label
Per label
Q 6 hr prn for allergic reaction
Yes
No
Calamine lotion
Per label
Per label
For allergic reaction–poison ivy
Yes
No
Neosporin
Per label
Per label
For minor cuts, abrasions prn
Yes
No
Betadine
Per label
Per label
Prn – cleanse wounds
Yes
No
“Sting kill”
Per label
Per label
Insect sting sites prn
Yes
No
Hydrocortisone
Per label
Per label
3-4 times daily prn for pruritis
Yes
No
Cream .5 %
Imodium AD
Per label
Per label
Loose stools – not to exceed 4
Yes
No
doses per day
Sucrets lozenges
Per label
Per label
Prn for throat irritation
Yes
No
RID shampoo
Per label
Per label
Prn for lice infestation
Yes
No
Anbesol
Per label
Per label
Prn for mouth pain
Yes
No
Dermoplast
Per label
Per label
Prn –superficial sunburns – pain
Yes
No
Prescription Medications: List all additional prescription medications that did not fit on Part A of the Annual
Health and Medical Record. (If additional space is needed, please photocopy this page).
Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
Note: Be sure to bring medications in original containers and make sure they are NOT expired, including
inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication while at camp.
Medication
Dosage
Frequency
Reason for Medication
Approx. Date Started
Temporary
Permanent
Parent’s Signature is Required: ___________________________________ Date: _____________________
Camper’s Health Care Provider Name: _______________________________
Office phone number: __________________________
Address: ________________________________________________________
License number: ______________________________
Physician’s Signature is Required: ___________________________Date: _________________
Last name: ________________________________ DOB: ____________________

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