5141.21 FORM #1

SEYMOUR PUBLIC SCHOOLS

Seymour, Connecticut

INDIVIDUAL STUDENT MEDICATION RECORD

_____Controlled Substance  _____Non-Controlled Substance

____________________________________                     __________________________________

Student’s Name             Grade/Home Room                     Physician/Dentist Ordering      Phone No.

Medication

__________________________________

Drug (Name)  Dosage/Time Ordered

__________________________________                ___________________________________

                    Form                                                        Parent’s Name                         Phone No.

__________________________________

Strength                                                                        ___________________________________

                                                                                     Received From                               Date Rec’d

Route  Administered From/To (Dates)

___________________________________              ____________________________________

                                                                                     Pharmacy                      Date to Reorder

___________________________________

Student’s allergies to food or drugs:                              ____________________________________

                                                                                    Prescription                       Prescription Date

___________________________________

Condition for which drug is being administered:

___________________________________              ____________________________________

Side Effects of medication to be observed:                    Rec’d Checked By                    Quantity

File in Student’s Cumulative Health Records when medication has been completed or discontinued.