Narcan Form
Today’s Date
-
Month
-
Day
Year
Date
Patient
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Unknown
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Call
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date of Arrival
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Indicators of Overdose
Slow Breathing
Blue Lips
No Pulse
Drug Paraphernalia Present
No Breathing
Slow Pulse
Pin Point Pupils
Bystanders Indicate Opiate OD
Number of Dose/Applicators (4mg each)
Response to Medication
None
Responsive and Alert
Responsive but Sedated
How Long to Take Effect
Less than 1 minute
1-3 Minutes
3-5 Minutes
Greater than 5 minutes
Never
Other Actions
Sternum Rub
Recovery Position
CPR
Oxygen Given
AED
Rescue Breathing
Second Narcan Given
Incident Number
Suspected Drugs
Alcohol
Crack
LSD
Methamphetamine
Oxycodone
Suboxone
Benzodiazepine
Fentanyl
MDMA
PCP
Synthetic Marjiuana
Cocaine
Heroin
Methadone
Over the Counter
Prescription Drugs
Other
Narrative
*
Submit
Should be Empty: