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
Indicators of Overdose

Slow BreathingBlue LipsNo PulseDrug Paraphernalia PresentNo BreathingSlow PulsePin Point PupilsBystanders Indicate Opiate OD
Number of Dose/Applicators (4mg each)
Response to Medication

NoneResponsive and AlertResponsive but Sedated
How Long to Take Effect

Less than 1 minute1-3 Minutes3-5 MinutesGreater than 5 minutesNever
Other Actions

Sternum RubRecovery PositionCPROxygen GivenAEDRescue BreathingSecond Narcan Given
Incident Number
Suspected Drugs

AlcoholCrackLSDMethamphetamineOxycodoneSuboxoneBenzodiazepineFentanylMDMAPCPSynthetic MarjiuanaCocaineHeroinMethadoneOver the CounterPrescription DrugsOther
Narrative*
Should be Empty: