Meddac Ft Meade Form 706 Dec 2014

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FORT MEADE MEDDAC SELF-CARE OVER-THE-COUNTER REQUEST FORM
SECTION I – PATIENT’S CERTIFICATION
1. I certify that:
a.
I do not wish to see a provider for advice before receiving the medication indicated below.
b. I understand that the medication is for use only in minor illnesses/conditions.
c.
If symptoms persist for more than 48 hours, I will consult a medical professional.
d. The person requesting this medication is not under the age of 18 years.
e.
The medication is only being used by the patient named below.
2. I further certify that __________________________________________________________, _____________________is not –
(Patient’s name)
(Date of birth)
a.
On flying status.
b. Allergic to any medication selected.
c.
Intending to use the medication for any purpose other than that recommended on the package labeling.
Name of patient, parent, or guardian
Signature
Prefix-SSN
Date
SECTION II – MEDICATIONS
There is a limit of two (2) medications per individual per 30-calendar day period.
Misuse of this program will result in loss of privileges.
Drug names appearing below in parentheses are of commonly used brand/trade names and are used as examples only.
ANY AGE:
o
Bacitracin ointment 1oz [
]
TOPICAL ANTIBIOTIC
o
Saline (Deep Sea eq) nasal mist 45mL [
/
]
ALLERGY
SINUS
o
Simethicone (Mylicon eq) 40mg/0.6mL liquid 30mL [
]
GAS
TWO YEARS & OLDER:
o
Acetaminophen (Tylenol eq) 160mg/5mL (child) liquid 118mL[
/
] *
PAIN
FEVER
o
Acetaminophen (Tylenol eq) 80mg chewable tablets 30s [
/
]
PAIN
FEVER
o
Clotrimazole (Lotrimin eq) 1% cream 1/2oz [
]
TOPICAL ANTIFUNGAL
o
Hydrocortisone 1% cream 1oz [
-
]
TOPICAL ANTI
ITCH
o
Ibuprofen (Motrin eq) 100mg/5mL liquid 118mL [
/
] *
PAIN
FEVER
SIX YEARS & OLDER:
o
Acetaminophen (Tylenol eq) 325mg tablets 100s [
/
]
PAIN
FEVER
o
Cetirizine (Zyrtec eq) 10mg tablets 30s [
/
]
ALLERGY
SINUS
o
Diphenhydramine (Benadryl eq) 25mg capsules 24s [
/
]
ALLERGY
SINUS
o
Diphenhydramine (Benadryl eq) 12.5mg/5mL liquid 120mL [
/
]
ALLERGY
SINUS
o
Loperamide (Imodium AD eq) 2mg capsules 12s [
]
DIARRHEA
o
Milk of Magnesia liquid 473mL [
]
CONSTIPATION
o
Pseudoephedrine (Sudafed eq) 30mg tablets 24s [
/
]
ALLERGY
SINUS
o
Pseudoephedrine (Sudafed eq) 30mg/5mL liquid 118mL [
/
]
ALLERGY
SINUS
TWELVE YEARS & OLDER:
o
Alum/Mag OH (Maalox Max eq) liquid 355mL [
,
]
GAS
HEARTBURN
o
Carbamide (Debrox eq) 6.5% ear drops 15mL [
]
EAR WAX REMOVAL
o
Guaifenesin (Robitussin eq) liquid 118mL [
]
COUGH
o
Guaifenesin/Dextromethorphan (Robitussin DM eq) liquid 118mL [
]
COUGH
o
Ibuprofen (Motrin eq) 200mg tablets 24s [
/
]
PAIN
FEVER
SIXTEEN YEARS & OLDER:
o
Aspirin 81mg enteric coated tablets 120s [
/
]
PAIN
FEVER
o
Bismuth Subsalicylate (Pepto Bismol eq) 262mg chewable tablets 30s [
,
,
]
DIARRHEA
HEARTBURN
NAUSEA
* Weight-based dosing may be provided by a pharmacist for patients < 2 years of age.
MEDDAC (Ft Meade) Form 706, DEC 2014
Previous editions are obsolete and will not be used.

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