Dear Doctor,
Please indicate which of the following medications may be taken by your patient. All medication will be taken per your instruction (Prescription) or as stated on the bottle. Please cross off any medications you do NOT wish your patient to take. Feel free to add any additional on the space provided below. 1. Acetaminophen (Tylenol) 325 mg, 1 -2 tablet every 4 hours as needed for minor pain. 2. Milk of Magnesia, 1 table spoon as needed as laxative. 3. Antacid, take as directed on bottle. 4. Metamucil or Fiber All, take per directions on bottle for treatment of occasional constipation or restore regularity. 5. Imodium AD, Take as directed on box to stop diarrhea. 6. Glycerin Suppository, 1 every 6 hours as needed for constipation. 7. Fleets Enema, 1 every 6 hours as needed for constipation (impaction). 8. Ducolax, Ex-Lax, Take as directed on bottle to use as laxatives. 9. Pepto-Bismol, as directed on bottle for upset stomach. 10. Muscle Rub- Ben Gay, Asper Cream, Ice Hot, as directed for sore muscles. 11. Cough Syrup, Resident choice and per instruction on bottle. 12. Cough Drops, Resident choice for sore throat. 13. Triple Antibiotics Ointment, per direction on labels for minor cuts and abrasions. 14. Desitin, For minor rash. 15. Vitamins, as directed on bottle. 16. Other 17. Other 18. Other 19. Other Physician Signature: Date