Medication Screening Form SAMPLE

This form is a SAMPLE only. Coordinate with the local Department of Health to obtain the approved Medical Screening Form for your Closed POD

Medication Screening Form • SAMPLE Head of Household Question 1 Question 2 Question 3 Decision Chart • STAFF USE ONLY Name ______Is this person Is this person Is this person: Answer 1 Answer 2 Answer allergic to or allergic to or Allergic Allergic 3 Address ______. In second should not should not or not to or not to half of Child, City, State, Zip ______take: take: take take a pregnan Provide pregnancy? Doxy- floxacin? t, or Phone ______. Doxycycline . Ciprofloxaci . Breast- cycline? breast- ? n (Cipro)? feeding? feeding? . Tetracyclin . Levofloxaci . A child No / DK No / DK No Doxy e? n Step 1 In the rows below, list all under 8 (Vibramycin (Levaquin)? No / DK No / DK Yes / DK Cipro household members for whom you are years old? ) picking up medication today. Place YOUR . Other No / DK Yes Any Doxy name in the first row. . Minocycline floxacin? Yes No / DK Any Cipro Step 2 For each person listed, answer all ? three questions. Yes Yes Any Refer Key DK = Don’t Know • ANY = Any Answer (Y, N, DK)

Yes, No, Don’t Yes, No, Yes, No, Don’t Check Medication to Provide • STAFF Affix Label Last Name, First Know? Don’t Know? USE ONLY Here Name Know ? 1 Doxy Cipro Referral Reason

2 Doxy Cipro Referral Reason

This form is a SAMPLE only. Coordinate with the local Department of Health to obtain the approved Medical Screening Form for your Closed POD This form is a SAMPLE only. Coordinate with the local Department of Health to obtain the approved Medical Screening Form for your Closed POD

Add totals for Doxy and Cipro columns: ► Step 3 Each person should take the medication checked in his or her row.

This form is a SAMPLE only. Coordinate with the local Department of Health to obtain the approved Medical Screening Form for your Closed POD