Appendix m b

Ohio Department of Health
Three-Page NAPH
Anthrax Prophylaxis Screening, Consent, and Declination
Patient information: Fill out or Prefix the label
Last name
Drug Allergies: (Note: Examples. Section relates to specific dispensed meds!)
Are you allergic to ciprofloxacin or another quinolone antibiotic? Are you allergic to doxycycline or tetracycline? Have you had a serious reaction to any other antibiotic? If yes, list medication and describe the reaction Current Medication and Medical History: (Note: Examples. Section relates to specific dispensed meds!)
Are you currently taking seizure medications? Are you currently taking probenicid (Benemidg)? Are you currently taking cyclosporine (Neoralg, Sandimmuneg)? Are you currently taking warfarin (Coumading)? Are you currently taking SucralfaCarafateg), colestipol (Colestidg), cholestyramine (Questran(R)) Are you currently taking antacids, calcium? or iron supplements? Are you currently on dialysis or has your physician discussed the possibility of dialysis-with you? Reproductive history — for females only
Are you currently using any form of birth control? If yes, are you taking oral contraceptives? Symptoms present during past 1 week: (Note: Section relates to specific disease/exposure situation!)
Respiratory symptoms (cough/shortness of breath/chest pain) New skin lesions (blisters, skin ulcers, black lesions) Hospitalized in the past month for pneumonia, Meningitis, or unexplained infectious illness For screener/dispenser use only
Patient disposition: (Example: Section relates to specific dispensed meds!)
Dispense Ciprofloxacin if no allergy to ciprofloxacin or other quinolones and no other contraindications.
Dispense Doxycycline if ciprofloxacin or other quinolones allergy and no Doxycycline or other tetracycline allergy or other contraindications.
If patient is allergic to both ciprofloxacin and doxycycline or answered ‘Yes’ to any contraindications,
refer to medical evaluator and do not sign this form.
Screener / Dispenser
Signature
Medication Dispensed (check and fill in lot #)
Note: specific medications/dosage/frequency to be deten-nined specific to the situation—consistent with the Standing Orders—and included here.
Medication
Dose (mg)
Frequency
Lot number
For medical evaluator use only
MD / PA / RN / NP/ Pharmacist note (include pertinent medical history, current medications, and allergies)
Medication dispensed
Referral
Medical evaluator
Signature
Consent / declination for medication
a I have discussed the risks and benefits of the recommended medication with the ___________________________________________ staff and I consent to the medication indicated above.
Individual or authorized person
Signature
a I have discussed the risks and benefits of the recommended medication with the staff and I decline the recommended medication.
Individual or authorized person
Signature

Source: http://marionpublichealth.org/PDFs/ODH%203-page%20NAPH%20Form--%202006.pdf