Name:
Name of medicine:
Directions:
3 times a day for
days
1
2
3
4
5 mL
Or
by mouth
15 mL
10 mL
5 mL
12.5 mL
7.5 mL
2.5 mL
Date medicine started:
Circle the starting dose and ending dose. Check ( ) the correct box each time you give your child the medicine.
Day
Time:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
The H.E.L.P. Project © 2014 New York University School of Medicine / Bellevue Hospital Center