Troop/Crew 464 Medical Treatment Statement

(Info here will be used by Troop/Crew Medic when giving First Aid)

 

Scout Name____________________________                  Date________________

 

Scout Outing to _________________________                  Period Covered __________________

 

My son, _________________ can be treated with the following over-the-counter (OTC) medications:

      (First name)
    

(Please initial after each acceptable item. Circle the "X" if children's dose needed.)
 

Aleve ________                                                Pepto Bismol _____________

 

Aspirin ________                                              Mylanta ________   X

 

Tylenol (fever) ______    X                               Dramamine (original formula) __________
 
Advil (pain)______    X                                    
Dramamine (Non drowsy formula) _________ 
 
Motrin (pain)______       X                               
Imodium (for diarrhea) ______   X  
 

Sudafed _______     X                                       Benedryl (for minor allergic reactions) _____   X   

 

Claritin (antihistamine) _______    X                 Betadine swab (wound cleaner) _______

 

Tums _______                                                   Cortaid (Hydrocortisone anti itch cream) ______

 

All of the listed meds are OK ___________       Circle if copy of Insurance Card attached
        
Additionally, my son is allergic to the following (circle all that apply):

 

Bee Sting  Peanuts  Hard Work  Iodine  Sulfa Drugs  Penicillin  _____________    _____________

         (Fill in here)           (Fill in here)

Or

No known allergies (circle here if applicable and Initial _____________)

Known history of any acute allergic reactions: ___________________________________________________________

I am providing the following Prescription Meds or OTC Meds for the following conditions:  _________________________

Insurance Carrier Name _____________________________  Insurance Phone # _________________

 

Insurance Policy/Record Number ___________________  Additional comments here: ____________

 

_________________________________________________________________________________

 

______________________________                     _______________________________

 (Signature of Parent/Guardian)                                      (Print Parent/Guardian name)