Child Name: ______________________________
Monthly Medicine Record: Month ____________ Year _______
Child Known Allergies:
Parent Permission to give medicine: I give my permission for the child care business to give the following medicine(s) to my child.
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
1
care:
Refrigeration
not required
2
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Parent permission to contact pharmacy and physician: I give my permission for the child care business to contact my child’s
pharmacy and physician should questions arise or a situation occur that involves my child and the medication.
Parent Name (print): _______________________________ Parent Signature: _______________________________ Date: _______
1
The time of day for the medicine needs to be consistent between home, child care and other programs where the child is located like school. Ask
the parent when the medicine is given at home so medicine doses may be evenly spaced for maximum benefit.
2
The medicine may need to be given before meals, after meals, with food, with a specific liquid (water or milk). All instructions should be written on
the medicine label or instructions. When in doubt, call the pharmacy where prescription medicine was dispensed.
January 2007
Child Name: ______________________________
Monthly Medicine Record: Month ____________ Year _______
Child Known Allergies:
Parent Permission to give medicine: I give my permission for the child care business to give the following medicine(s) to my child.
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
1
care:
Refrigeration
not required
2
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Parent permission to contact pharmacy and physician: I give my permission for the child care business to contact my child’s
pharmacy and physician should questions arise or a situation occur that involves my child and the medication.
Parent Name (print): _______________________________ Parent Signature: _______________________________ Date: _______
1
The time of day for the medicine needs to be consistent between home, child care and other programs where the child is located like school. Ask
the parent when the medicine is given at home so medicine doses may be evenly spaced for maximum benefit.
2
The medicine may need to be given before meals, after meals, with food, with a specific liquid (water or milk). All instructions should be written on
the medicine label or instructions. When in doubt, call the pharmacy where prescription medicine was dispensed.
January 2007
Attach
Monthly Medicine Record
Child
Child Name: ________________________
Photo
Day of Month
Month ____________
Here
Year _______
Time of
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Medicine, Dose
Day
and Route
Example: Amoxicillin
*
250 mg., 1 teaspoon,
10 am
orally
* Place your initials in the box showing the medicine was given. Use an “A” when a child is absent. Use an “O” when medication is not given for any reason.
Document the reason the medication was not given and document that the parent was informed
Instructions for using Medicine Record:
Third – Last Column: The person who measures and gives the medicine must place their
initials in the appropriate row (for time) and column (for date) that the medicine was given.
First Column: Record the medicine name, dosage, and route.
Use columns numbered from 1-31 for the date. The person who measures the medicine
Second Column: Record the time(s) of day the medicine is to be given at child care. If the
dosage is the only person allowed to give the medicine.
medicine is given more than one time a day, use a separate row for each time of day the
medicine is to be given.
Call the Healthy Child Care Iowa talkline 1-800-369-2229
to order free copies of this form.
Iowa Poison Control Center: 1-800-222-1222
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