CAREGIVER’S SUPPORT NETWORK

SICK CHILD CARE

Child’s Name: _____________________________________ Birth date: _________________________

Current Weight: _____________________

Fever Reliever: _____________________________ dosage: _____________________________

(Type/Brand) frequency: __________________________

Decongestant: ______________________________ dosage: _____________________________

(Type/Brand) frequency: __________________________

Cough Suppressant: __________________________ dosage: _____________________________

frequency: __________________________

Anti-emetic: _______________________________ dosage: _____________________________

frequency: __________________________

Anti-diarrhea: ______________________________ dosage: _____________________________

frequency: __________________________

Other: ____________________________________ dosage: _____________________________

frequency: __________________________

Other: ____________________________________ dosage: _____________________________

frequency: __________________________

Other: ____________________________________ dosage: _____________________________

frequency: __________________________

Please include any alternative treatments such as homeopathic or herbal compounds.

Diaper Ointment: ___________________________________________________________________

(Type/Brand and when to apply)

Other Ointment or salve: ______________________________________________________________
(Type/Brand and when to apply)

Other Pertinent information:

N on-prescription Medication remains valid through____________________ Date

Physician’s Signature: _____________________________________________ Date: _______________

Address: _________________________________________________ Telephone: _ _________

Parent/Guardian Signature: _________________________________________ Date: _______________