Narcan Form

Narcan Form
Today’s Date

MonthDayYear
Date
Patient

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Incident Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Call

MonthDayYear
Date
Hour MinutesAM/PM Option
Date of Arrival

MonthDayYear
Date
Hour MinutesAM/PM Option
Slow BreathingBlue LipsNo PulseDrug Paraphernalia PresentNo BreathingSlow PulsePin Point PupilsBystanders Indicate Opiate OD
Number of Dose/Applicators (4mg each)
NoneResponsive and AlertResponsive but Sedated
Less than 1 minute1-3 Minutes3-5 MinutesGreater than 5 minutesNever
Sternum RubRecovery PositionCPROxygen GivenAEDRescue BreathingSecond Narcan Given
Incident Number
AlcoholCrackLSDMethamphetamineOxycodoneSuboxoneBenzodiazepineFentanylMDMAPCPSynthetic MarjiuanaCocaineHeroinMethadoneOver the CounterPrescription DrugsOther
Narrative*
Should be Empty: