STANDING MEDICATION ORDERS FOR THE MINNESOTA ACADEMIES *form #5
These medications have been reviewed and signed by a local physician (Dr. D. McIntyre)
1. Acetaminophen every 4-6 hours as needed (not to exceed manufacturer dosing guidelines) See chart below. For headache,
sore throat, pain, or fever. Do not exceed 4 doses in 24 hours.
Dosage for Children’s Tylenol (80 mg/tablet)
Weight (LB) 36-47 48-59 60-71 72-95
Age 4-5 years 6-8 years 9-10 years 11 years
Tablets 3 4 5 6
Dosage for JR Strength Tylenol (160mg/tab or tsp)
Weight (LB) 36-47 48-59 60-71 72-95 96 and over
Age 4-5 years 6-8 years 9-10 years 11 years 12 years
Tablets 1 ½ (1 ½ tsp) 2 2½ 3 4
Dosage for Regular Strength Tylenol (325mg/tab) or Extra Strength Tylenol (500mg/tab)
Weight 96 pounds and over
Age Adults and children 12 years of age and older
Tablets 2 tablets every 4 – 6 hours as needed
2. Ibuprofen: For relief of pain and fever. Children 12 years of age and older: 200-400mg, Children 6-8years: 200mg, 9-10
years: 250mg, 11 years: 300mg. Dose may be repeated every 6-8 hours prn. (Do not exceed 3 doses in 24 hours)
3. Tussin DM Cough Formula: For relief of coughs and chest congestion. Children 12 years and older: 2 tsp. every 4 hours prn.
Children 6-12 years: 1 tsp. every 4 hours prn. Children under 6: ½ tsp every 4 hours prn.
4. Sore Throat Spray: For relief of sore mouth, sore throat pain, and canker sores. Children 12 years and older: Spray 5 times
on affected area. Children under 12 years: Spray 3 times.
5. Suphedrine 30mg: For relief of nasal congestion. Children 12 years and older: 2 tablets every 4-6 hours prn. Children 6-12
years: 1 tablet every 4-6 hours prn. * The Academies will not supply Suphedrine (Sudafed) but parents/guardians may
provide a supply to the health clinic for their child.
6. Benadryl 25 mg: For relief of runny nose, sneezing, itching of the nose or throat, and itchy, watery eyes. Children 12 years and
older: 1-2 tablets every 4-6 hours prn. Children 6-12 years: 1 tablet every 4-6 hours prn.
7. Loperamide Hydrochloride Tablets 2mg (Anti-Diarrheal): For relief of symptoms of diarrhea. Children 12 years and older:
Take 2 tablets after the first loose bowel movement and 1 tablet after each subsequent loose bowel movement. Children 6-12
years: Take 1 tablet after the first loose bowel movement and ½ tablet after each subsequent loose bowel movement.
8. Antacid Tablets 500mg (Tums): For relief of acid ingestion and heartburn. Chew 2-4 tablets as symptoms occur.
1. Triple Antibiotic Ointment (bacitracin): To help prevent infection in minor cuts, scrapes, and burns.
2. Hydrocortisone 1% Cream: For relief of itching associated with rashes and inflammation. Apply to affected area 3-4 per day.
3. Diphenhydramine Hydrochloride 2% (Benadryl Cream): Used for relief of itching from insect bites or rashes from plants,
such as poison ivy. Apply to affected area 3-4 times a day. Consult a physician for children under 12 years of age.
4. Ben-Gay: For relief of muscle aches. Apply generously and gently massage until Ben-Gay disappears. Repeat 3-4 times per day.
5. Vicks VaporRub: For relief of nasal congestion and coughing due to colds.
6. Tolnaftate Cream USP, 1%: For treatment of ringworm or athlete’s foot. Apply thin layer over affected area 2 times per day.
7. Eye wash (drops) sterile isotonic solution: For cleansing of irritated eyes and/or removal of loose foreign material. Apply as needed.
1. Warm Packs or Soaks for infection.
2. Cold Packs for sprains, bruises, or other traumatic injuries.
3. Povidone Iodine Scrub Solution as needed for cleansing of wounds.
4. Band-aid Hurt-Free Antiseptic Wash for cleansing of wounds as needed.
5. Aloe Vera Gel or Lotion for sunburn.
6. Cough Drops for cough.
7. Carmex for cold sores, fever blisters, and chapped lips.
8. Anbesol for cold sores/canker sores.
9. Fleets Enema as needed for constipation – not to exceed one in 24 hours.
10. Bisacodyl (Ducolax) suppository as needed for constipation.
I consent to the use of these over-the-counter medications for my child. They will only be administered as needed. Dosing
may not exceed the manufacturer’s recommended dose. I have reviewed the medications and have crossed out any
medications that I do not want my child to receive.
Student Name: ____________________ Parent signature: ___________________ Date: ____________