Medication History Consent Form

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					                          (Name of Local Health Department (LHD)) - Strategic National Stockpile
                                        (LHD Address) and (LHD Phone Number)
                                       Family Medical History and Consent Form
                   SECTION 1: HOUSEHOLD MEMBERS (TO BE COMPLETED BY PATIENT)
                 Household Members (Person Completing Form = A, Household Members = B, C, D, etc.).
ID              Last Name               First Name            M.I.     Sex      Age     Weight                                     Rx Lot #

A                                                                                               M or F

 B                                                                                              M or F

C                                                                                               M or F

D                                                                                               M or F
Date ___________     Primary Telephone # _______________________________________
Address __________________________________ City _______________________ State ____ Zip _______

                      SECTION 2: MEDICAL HISTORY (TO BE COMPLETED BY PATIENT)
Answer all questions (A) for yourself AND household members using assigned letter (B-C-D)
1. Are currently experiencing any of the following: Fever, headache, extreme
   tiredness, dry cough, sore throat, runny or stuffy nose, muscle aches, or nausea.                                ___ ___ ___ __
2. Have you received the intranasal influenza vaccine within the last 14 days?                                       ___ ___ ___ __
3. Do you have any other medical concerns?                                                                          ___ ___ ___ ___
4. Do you, or will you be receiving kidney dialysis?                                                                ___ ___ ___ ___

                     SECTION 3: INFORMED CONSENT (TO BE COMPLETED BY PATIENT)
I HAVE: 1) Been informed of reasons why I, and/or my family, are receiving medication; 2) Received a medication information sheet
indicating the risks and benefits of the medication, its side effects, and where I will be able to receive additional information if side effects
were to develop; 3) Received information about the infectious agent and 4) Had an opportunity to have my questions answered. 5) I
understand that the medication is in a non-child resistant container. 6) Will dispose of this medication no later than 1 year from date of
dispensing.
I consent to this treatment for household members and myself. ______________________________________________________
                   SECTION 4: PRESCRIBING INFORMATION (COMPLETED BY PROVIDER)
                                           Check prescribed medication & print ID letter (i.e. A-D).
Relenza: Treatment or Prophylaxis for Adults and children at least 7 years old:
      Relenza Treatment Two 5mg inhalations (10mg total) TWICE daily for 5 days ID Letter(s):________
      Relenza Prophylaxis Two 5mg inhalations (10mg total) ONCE daily for 10 days ID Letter(s):________
Tamiflu for Adults and children at least 13 years old:
      Tamiflu Treatment 75mg TWICE daily for 5 days                                ID Letter(s): ____________
      Tamiflu Prophylaxis 75mg ONCE daily for 10 days                              ID Letter(s): ____________
Less than 13 years old or < 88lbs:
 Tamiflu Prophylaxis for children 1 year of age or older: Weight adjusted doses
 Body Weight in kg Body Weight in lbs DOSAGE                  Treatment/Letter                                  Prophylaxis/Letter
 ≤15 kg                     ≤33 lbs                      30 mg once daily         5 Days   //                   10 Days   //
 >15 to 23 kg               >33 lbs to 51 lbs            45 mg once daily         5 Days   //                   10 Days   //
 >23 to 40 kg               >51 lbs to 88 lbs            60 mg once daily         5 Days   //                   10 Days   //
 >40 kg                     >88 lbs                      75 mg once daily         5 Days   //                   10 Days   //
LHD/HOSPITAL STAFF REMINDER (IF DISPENSING MEDICATION)– Place in Ziplock bag and seal:
 Patient copy of Patient and Family Medical History and Consent form
 Medication                                                            Date __________________________________________
 EUA Drug Information Sheet
                                                              Staff Signature __________________________________

     05-20-2009      Retain one copy of this form, and send original to pharmacy (if applicable)         (Medical Director Name)
                                                                                                          Medical Director
                                                                                                          (Name of LHD)

				
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