Medication Log
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Student: ___________________________________________
Medication / Dosage: ____________________________________________
MEDICATION ADMINISTRATION LOG
** One log per student / One log per medication
MONTH YEAR
WEEK ONE M
T
W
T
Administration Time: _____________________
WEEK TWO F
M
T
W
T
Please place in Health Insert when completed.
WEEK THREE F
M
T
W
T
School Year: ___________________
WEEK FOUR F
M
T
W
T
WEEK FIVE F
M
T
W
T
August September October November December January February March April May June July Comments:
Medication Count Log Date Count Received Parent/Guardian:
_______________________
Address: _______________________________________ Phone (home): ___________________(work)_________ School: ________________Grade: _________Rm: _____ Teacher: _________________________________________
Diagnosis: ________________________________________
CODES
INITIALS
Signature
____Oral ____Topical ____Inhale ____Other_______ Side Effects: _____________________________________ Physician: _________________Phone:_______________
A Absent H Holiday N No Meds R Refused
___________ ___________ ___________ ___________
_____________ _____________ _____________ _____________
Please note time / initial in date blocks when medication is administered. Notify nurse of concerns and / or changes. Utah County Health Department Form 4/00 LH
F
Medication / Dosage: ____________________________________________
MEDICATION ADMINISTRATION LOG
** One log per student / One log per medication
MONTH YEAR
WEEK ONE M
T
W
T
Administration Time: _____________________
WEEK TWO F
M
T
W
T
Please place in Health Insert when completed.
WEEK THREE F
M
T
W
T
School Year: ___________________
WEEK FOUR F
M
T
W
T
WEEK FIVE F
M
T
W
T
August September October November December January February March April May June July Comments:
Medication Count Log Date Count Received Parent/Guardian:
_______________________
Address: _______________________________________ Phone (home): ___________________(work)_________ School: ________________Grade: _________Rm: _____ Teacher: _________________________________________
Diagnosis: ________________________________________
CODES
INITIALS
Signature
____Oral ____Topical ____Inhale ____Other_______ Side Effects: _____________________________________ Physician: _________________Phone:_______________
A Absent H Holiday N No Meds R Refused
___________ ___________ ___________ ___________
_____________ _____________ _____________ _____________
Please note time / initial in date blocks when medication is administered. Notify nurse of concerns and / or changes. Utah County Health Department Form 4/00 LH
F
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