Physical Examination And Medical History Form (Page 4 of 4) in pdf

MINOR WOUNDS AND BURNS

Notify the nurse if area appears infected; if there is a question about the need for stitches; or if

burned area is blistered or skin broken.

Bacitracin Ointment (T) apply to wound 1 to 3 times a day prn. Do not use on a deep or

puncture wounds or burns unless directed by physician.

RELIEF OF MILD SUNBURN OR ITCHING

(due to poison ivy/oak, insect bites or other minor skin irritation)

Notify nurse before applying to a rash. Do not to blistered, raw or oozing skin. Discontinue use

and notify MD if burning sensation occurs, rash develops, or condition persists after 7 days.

Apply Calamine Lotion (T) apply liberally 3-4 times a day prn. Shake well. Clean area with

soap and water and dry before each application.

RASHES/SKIN IRRITATIONS/SKIN INFLAMMATION

Notify the nurse prior to use. Notify MD if condition worsens or symptoms persist after 7 days.

1% HC Cream (T) apply 3-4 times a day prn. Do not apply to an area larger than 10" by 10"

unless directed by MD. Avoid eye, eyelid and oral contact.

ATHLETE'S FOOT

Refer to MD if not improved after 2 weeks. Participant should was feet daily and dry well.

Encourage use of clean, white cotton socks.

Micatin (Miconazole) (T) apply cream sparingly and massage in well between toes and affected

areas in the morning and at bedtime.

DANDRUFF

Notify the nurse at next visit if there are severe or patchy areas on the scalp.

Selsun Blue Shampoo (Selenium Sulfide) (T) use 1-2 times per week for dandruff. Shake well

before use, lather, rinse and repeat. Rinse well and avoid getting into eyes.

DRY SKIN AND LIPS

Notify the nurse if areas do not respond to treatment in 5 days or if rash develops.

May use non-medicated hygiene/grooming products as indicated or as directed by the nurse.

Carmex (T) apply to lips 2-4 times/day prn for chapping, fever blisters, or cold sores.

PREVENTION

Sunburn - may use any sunblock with a minimum Sunburn Protection Factor of 15. Follow

directions on the bottle.

Insect Bites - May use insect repellent as directed on container. Use insect spray with DEET to

help protect from Deer Ticks

EPI PENS – If participant identifies self as allergic to bee strings an EPI pen will be available.

OTHER

Benadryl 25-50 mg q 6 h PRN WITH NURSE DIRECTION

Physician Signature______________________________ Date _________________________

S:Forms – Medical OfficeStanding Order for Over the Counter Medications – 11/2010

Physical Examination And Medical History Form Page 4