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Audio History Form
Frederick County Fire Fighters
Department:___________________ Shift:______ Job Title:__________________________ Sex: ____Male ____Female Type of Test: (Circle one) PREPLACEMENT BASELINE (Initial) ANNUAL RETEST TERMINATION OTHER Have you been exposed to noise within the last 14 hours? [ ] Yes [ ] No Explain:__________________________________________________________________ How do you rate your hearing? [ ] Unknown [ ] Very poor [ ] Average [ ] Good [ ] Very good Hearing Protection, Do you wear while at work? [ ] Not used [ ] Seldom Used [ ] Used sometimes [ ] 1/2 time [ ] Usually used [ ] Always used If yes, what type of hearing protection do you wear? [ ] Earplugs [ ] Earmuffs [ ] Both Brand?_______________________________________________________ MEDICAL HISTORY (Check the correct answer) 10. Ear pain [ ] Yes [ ] No 25. Scarlet Fever [ ] Yes [ ] No 11. Draining Ear [ ] Yes [ ] No 26. Measles [ ] Yes [ ] No 12. Dizziness/imbalance [ ] Yes [ ] No 27. Meningitis [ ] Yes [ ] No 13. Severe ringing [ ] Yes [ ] No 28. Diabetes [ ] Yes [ ] No 14. Sudden hearing loss [ ] Yes [ ] No 29. Kidney disease [ ] Yes [ ] No 15. Fluctuating hearing 30. Visible wax/object [ ] Yes [ ] No loss [ ] Yes [ ] No 31. Allergies [ ] Yes [ ] No 16. Fullness/discomfort [ ] Yes [ ] No 32. Family hearing loss[ ] Yes [ ] No 17. History of prior 33. High noise disease/ear problem [ ] Yes [ ] No exposure today [ ] Yes [ ] No 18. Recent prescription 34. History of prior ear drugs [ ] Yes [ ] No disease before test[ ] Yes [ ] No 19. High blood pressure [ ] Yes [ ] No 35. Head cold today [ ] Yes [ ] No 20. See MD for ears [ ] Yes [ ] No 36. Military service [ ] Yes [ ] No 21. Ear surgery [ ] Yes [ ] No 37. Noisy hobbies [ ] Yes [ ] No 22. Unconsciousness [ ] Yes [ ] No 38. Loud music/ 23. Wear hearing aid [ ] Yes [ ] No headphones [ ] Yes [ ] No 24. Mumps [ ] Yes [ ] No 39. Firearms/guns [ ] Yes [ ] No Explain any ‘Yes’ responses: __________________________________________________________________________________________________________________________________________________________ MEDICATIONS (Past & Present) (Please check appropriate boxes.) [ ] Aspirin, Bufferin, Excedrin (more than 6/day) [ ] Neomycin [ ] Streptomycin [ ] Gentamycin [ ] Quinine Explain any checked answers: __________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________ Employee Signature Date OTOSCOPIC EXAM: Right: [ ] Normal [ ] Abnormal ____________________Examiners Initials_____ Left: [ ] Normal [ ] Abnormal ____________________Examiners Initials_____ Comprehensive Medical History
Frederick County Fire Fighters
Allergies: Latex: _____ Yes _____ No Medication Allergies: _________________________________________________ Other Allergies:_______________________________________________________ Last Tetanus booster: __________ Current Medications: _________________________________________________ ______________________________________________________________________ Current Physician: ___________________________________________________ Medical Illnesses - check all that apply: ___ High Blood Pressure ___ Heart Disease ___ Lung Disease ___ Kidney Disease ___ Diabetes ___ Anemia ___ Seizures ___ Cancer ___ Stomach or Bowel Disorders: _______________________________________ ___ Fractures & Joint Injuries: _______________________________________ ___ Other: ____________________________________________________________ Surgeries: ____________________________________________________________ Social History - Check all that apply : ___ Tobacco use ___ Cigarettes: ___ packs/day ___ years ___ Cigars: ___ per day ___ years ___ Pipe: ___ years ___ Chew/Snuff: ___ years ___ Alcohol use ___ Drinks per week Place an X in the box if you have any of the conditions below now or in the past: (Caregivers: please comment on positive responses): Vision (Vision) __ 1. Do you use glasses?: Do you have: __ For reading __16. Chest pain on effort __ For distant vision __17. High blood pressure __ Contacts __18. Shortness of breath __ 2. Are you color blind? __19. Swelling of ankles __20. Heart murmur 3. Do you have: Have you had: __ Retinal disease __21. Heart attack __ Cataracts __22. Stroke __ Glaucoma __23. Rheumatic fever __ 4. Do you use eye medicine? __24. Heart failure __ 5. Have you had eye surgery? __25. Heart surgery __ 6. Have you had laser exposure? Hearing Respiratory Do you have Do you have: __ 7. Difficulty hearing __26. Chronic cough __ 8. Ear disease __27. Asthma __ 9. Ringing in the ears __28. Bronchitis __10. Abnormal hearing test __29. Hay fever __11. Do you use a hearing aid? __30. Emphysema __12. Have you had ear surgery? Have you had: __13. Ruptured ear drum? __31. Tuberculosis __14. Exposure to gunfire? __32. Lung cancer __15. Wear hearing protection? __33. Lung surgery __34. Silicosis __35. Asbestos Liver or Gastrointestinal __36. Black lung Do you have or have you had: Blood, Endocrine __37. Hepatitis Have you had: __38. Cirrhosis __39. Jaundice __63. Anemia __40. Frequent indigestion __64. Bleeding problems __41. Ulcer disease __65. Hormone problems __42. Colitis __66. Diabetes __43. Other intestinal problems __67. Thyroid problem __44. Do you have a hernia? __45. Have you had hernia surgery? Genitourinary: Musculoskeletal: Do you or have you had: Do you or have you had: __46. Kidney trouble __68. Back trouble __47. Bladder trouble __69. Disc problems/surgery __48. Kidney stones __70. Shoulder problems/surgery __71. Arm problems/surgery __72. Wrist problems/surgery Skin: __73. Hand problems/surgery __74. Hip problems/surgery __49. Do you have eczema? __75. Leg problems/surgery __50. Do you have psoriasis? __76. Knee problems/surgery __51. Any other skin conditions __77. Ankle problems/surgery __78. Foot problems/surgery Neurologic __79. Broken bones __80. Numbness, tingling, and/or __52. Tremors pain in hands or arms __53. Dizzy spells __54. Convulsions Communicable Diseases: __56. Nerve damage Have you had: __57. Serious head injury __58. Brain surgery __81. Chicken pox __59. Nervous breakdown __82. Measles __83. German Measles Are you taking medication for: __84. Mumps __85. Hepatitis A __86. Hepatitis B __60. Anxiety or depression __87. Hepatitis C __61. Epilepsy __62. Parkinson’s disease Please list all prior jobs: Company Name: Dates Employed: Job Description: _____________________________ ______________ ____________________________ _____________________________ ______________ ____________________________ _____________________________ ______________ ____________________________ _____________________________ ______________ ____________________________ Circle any of the following processes and/or jobs done in the past: Processes: abrasive blasting acid/alkali treatment degreasing electroplating foundry forging painting welding grinding or metal machining Industries: flour, feed or grain cotton processing rubber insulation quarry work construction farming petroleum shipyards Circle any of the following substances to which you have had regular exposure in the workplace: Fumes or dusts: silica coal asbestos talc fiberglass cotton dust sawdust other: ___________ Solvents: benzene carbon tetrachloride trichloroethylene naptha xylene other : _______________ Chemicals or gases : ammonia formaldehyde hydrogen sulfide cyanide sulfur dioxide chromium mercury lead cadmium nickel other: _____________________ Miscellaneous: radiation insecticides/herbicides cutting oils motor exhaust noise Have you ever needed medical care for exposure to any of the above? ___ Yes ___ No Type of problem: Skin: ___________ Lungs: _____________ Other: ________________________________ Work related injuries and illnesses: Year: Injury and treatment: Time off work: ______ ____________________________________________ _____________ ______ ____________________________________________ _____________ ______ ____________________________________________ _____________ ______ ____________________________________________ _____________ ______ ____________________________________________ _____________ ______ ____________________________________________ _____________ Yes No Explain if yes ___ ___ Have you ever applied for worker's compensation or disability payments for any injury or illness which developed on the job? Explain: ________________________________________________ ___ ___ Are you currently being treated by a doctor for a work related injury or illness? Explain: _______________________________________________________ ____________________________________________ _____________________ Employee Signature Date ____________________________________________ _____________________ Reviewed By Date OSHA Mandatory Respirator Medical Evaluation Questionnaire
29 CFR 1910.134
Frederick County Fire Fighters
Can you read: [ ] yes [ ] no Your employer must allow you to answer the questionnaire during normal working hours, or at a time that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it. Part A Section 1 (Mandatory). The following information must be provided by every employee who has been selected to use any type of respirator. Please Print 1. Today’s Date: ___/___/_____ 2. Your Name: ________________________ 3. Your Age: ______ 4. Your Social Security #: ____-___-_______ 5. Your Job Title: ___________________ 6. Your Date of Birth: ___/___/______ 7. Sex [ ] Male [ ] Female 8. Your Height: ___ feet ___ inches 9. Your Weight: ____ lbs. 10.Phone # where you can be reached to discuss your answers:(___) ____-_______ 11.The best time to call you at this number: ________ [ ] a.m. [ ] p.m. 12.Has your employer told you how to contact the health care professional who will review this questionnaire? [ ] yes [ ] no 13.Check the type of respirator you will use. (You can check more than one category) [ ] a. N,R, or P disposable respirator (filter-mask, non- cartridge type only). [ ] b. Other type (for example, half- or full-facepiece type, powered-air purifying supplied air, self-contained breathing apparatus). 14.Have you worn a respirator? [ ] yes [ ] no If yes, what type(s): ____________________________________________________________________________ ____________________________________________________________________________ Part A Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator. 1.Do you currently smoke tobacco, or have you smoked tobacco in the last month? [ ] yes [ ] no 2. Have you ever had any of the following conditions? a. Seizures (fits) [ ] yes [ ] no b. Diabetes (sugar disease): [ ] yes [ ] no c. Trouble smelling odors: [ ] yes [ ] no d. Claustrophobia (fear of closed-in places) [ ] yes [ ] no e. Allergic reaction that interfere with your breathing?[ ] yes [ ] no 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis [ ] yes [ ] no b. Asthma [ ] yes [ ] no c. Chronic bronchitis [ ] yes [ ] no d. Emphysema [ ] yes [ ] no e. Pneumonia [ ] yes [ ] no f. Tuberculosis [ ] yes [ ] no g. Silicosis [ ] yes [ ] no h. Pneumothorax (collapsed lung) [ ] yes [ ] no i. Lung cancer [ ] yes [ ] no j. Broken ribs [ ] yes [ ] no k. Any chest injuries or surgeries [ ] yes [ ] no l. Any other lung problem you’ve been told about [ ] yes [ ] no 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath: [ ] yes [ ] no b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: [ ] yes [ ] no c. Shortness of breath when walking with other people at an ordinary pace on level ground: [ ] yes [ ] no d. Have to stop for breath when walking at your own pace on level ground: [ ] yes [ ] no e. Shortness of breath when washing or dressing yourself: [ ] yes [ ] no f. Shortness of breath that interferes with your job: [ ] yes [ ] no g. Coughing that produces phlegm (thick sputum): [ ] yes [ ] no h. Coughing that wakes you early in the morning: [ ] yes [ ] no i. Coughing that occurs mostly when you are lying down: [ ] yes [ ] no j. Coughing up blood in the last month: [ ] yes [ ] no k. Wheezing: [ ] yes [ ] no l. Wheezing that interferes with your job: [ ] yes [ ] no m. Chest pain when you breathe deeply: [ ] yes [ ] no n. Any other symptoms that you think may be related to lung problems: [ ] yes [ ] no 5. Have you ever had any of the following cardiovascular or heart problems? a. Heart attack: [ ] yes [ ] no b. Stroke [ ] yes [ ] no c. Angina [ ] yes [ ] no d. Swelling in your legs and feet (not caused by walking) e. Heart Failure [ ] yes [ ] no f. Heart arrhythmia (irregular heart beat) [ ] yes [ ] no g. High blood pressure [ ] yes [ ] no h. Any other heart problem that you’ve been told about: [ ] yes [ ] no 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in the chest: [ ] yes [ ] no b. Pain or tightness in your chest during physical activity: c. Pain or tightness in your chest that interferes with your job: [ ] yes [ ] no d. In the past two years, have you noticed your heart skipping or missing a beat: [ ] yes [ ] no e. Heartburn or indigestion that is not related to eating: f. Any symptoms that you think may be related to heart or circulation problems: [ ] yes [ ] no 7. Do you currently take medication for any of the following problems? a. Breathing problems [ ] yes [ ] no b. Heart trouble [ ] yes [ ] no c. Blood Pressure [ ] yes [ ] no d. Seizures (fits) [ ] yes [ ] no 8. If you’ve used a respirator, have you ever had any of the following problems? (if you’ve never used a respirator, check the following box and go to question 9. [ ] Never Used a. Eye Irritation: [ ] yes [ ] no b. Skin allergies or rash [ ] yes [ ] no c. Anxiety [ ] yes [ ] no d. General weakness or face: [ ] yes [ ] no e. Any other problem that interferes with your use of a respirator: [ ] yes [ ] no 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary. 10.Have you ever-lost vision in either eye (temporarily or permanently): [ ] yes [ ] no 11.Do you currently have any of the following vision problems: a. Wear contact lenses: [ ] yes [ ] no b. Wear glasses: [ ] yes [ ] no c. Color blind: [ ] yes [ ] no d. Any other eye or vision problem: [ ] yes [ ] no 12.Have you ever had an injury to you ears, including a broken eardrum: [ ] yes [ ] no 13.Do you currently have any of the following hearing problems? a. Difficulty hearing: [ ] yes [ ] no b. Wear a hearing aid: [ ] yes [ ] no c. Any other hearing or ear problem: [ ] yes [ ] no 14.Have you ever had a back injury: [ ] yes [ ] no 15.Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs or feet: [ ] yes [ ] no b. Back pain [ ] yes [ ] no c. Difficulty fully moving you arms & legs: [ ] yes [ ] no d. Pain or stiffness when you lean forward or backward at the waist: [ ] yes [ ] no e. Difficulty fully moving your head up or down: [ ] yes [ ] no f. Difficulty fully moving your head side to side: [ ] yes [ ] no g. Difficulty bending at your knees: [ ] yes [ ] no h. Difficulty squatting to the ground: [ ] yes [ ] no i. Climbing a flight of stairs or a ladder carrying more than 25 lbs.: [ ] yes [ ] no j. Any other muscle or skeletal problem that interferes with using a respirator: [ ] yes [ ] no Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. 1.In your present job, are you working at high altitudes (over 5,000 ft) or in a place that has lower than normal amounts of oxygen: [ ] yes [ ] no If ‘yes’ do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you’re working under these conditions: [ ] yes [ ] no 2.At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: [ ] yes [ ] no If ‘yes’ name the chemicals if you know them: _____________________________________________________________________________ _____________________________________________________________________________ 3.Have you ever worked with any of the materials, or under any of the conditions listed below: a. Asbestos: [ ] yes [ ] no b. Silica: [ ] yes [ ] no c. Tungsten/Cobalt: [ ] yes [ ] no d. Beryllium: [ ] yes [ ] no e. Aluminum: [ ] yes [ ] no f. Coal: [ ] yes [ ] no g. Iron: [ ] yes [ ] no h. Tin: [ ] yes [ ] no i. Dusty environment [ ] yes [ ] no j. Any other hazardous exposures: [ ] yes [ ] no If ‘yes’ describe the exposure: 4.List any second jobs or side businesses you have: 5.List your previous occupations: 6.List your current & previous hobbies: 7.Have you been in the military service? [ ] yes [ ] no If ‘yes’ describe these exposures: 8.Have you ever worked on a HAZMAT team? [ ] yes [ ] no 9.Other than the medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications: [ ] yes [ ] no If ‘yes’ name the medications if you know them: 10.Will you be using any of the following items with your respirator(s)? a. HEPA Filters [ ] yes [ ] no b. Canisters (e.g. gas masks) [ ] yes [ ] no c. Cartridges [ ] yes [ ] no 11.How often are you expected to use the respirator: a. Escape only; no rescue [ ] yes [ ] no b. Emergency rescue only [ ] yes [ ] no c. Less than 5 hours per week [ ] yes [ ] no d. Less than 2 hours per day [ ] yes [ ] no e. 2 to 4 hours per day [ ] yes [ ] no f. Over 4 hours per day [ ] yes [ ] no 12.During the period you are using the respirator(s), is your work effort: a. Light (less than 200 kcal per hour): [ ] yes [ ] no If ‘yes’, how long does this period last during the average shift ____________ hours ____________minutes Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines. b. Moderate (200 to 350 kcal per hour) [ ] yes [ ] no If ‘yes’, how long does this period last during the average shift ____________ hours ____________minutes Examples of moderate work effort are sitting while nailing or filing, driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. c. Heavy (above 350 kcal per hour): [ ] yes [ ] no If ‘yes’, how long does this period last during the average shift ____________ hours ____________minutes Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.) 13.Will you be wearing protective clothing and/or equipment (other than the respirator) when you’re using the respirator: [ ] yes [ ] no If ‘yes’ describe this protective clothing and/or equipment: 14.Will you be working under hot conditions (temperature exceeding 77 degrees F) [ ] yes [ ] no 15.Will you be working under humid conditions: [ ] yes [ ] no 16.Describe the work you’ll be doing while you’re using your respirator(s): 17.Describe any special or hazardous conditions you might encounter when you’re using your respirator(s) (e.g., confined spaces, life-threatening gases): 18.Provide the following information, if you know it, for each toxic substance that you’ll be exposed to when you’re using your respirator(s) Name of toxic substance - #1: Estimated maximum exposure level per shift: Duration of exposure per shift: ------------------------------------------------------------------------- Name of toxic substance - #2: Estimated maximum exposure level per shift: Duration of exposure per shift: -------------------------------------------------------------------------- Name of toxic substance - #3: Estimated maximum exposure level per shift: Duration of exposure per shift: -------------------------------------------------------------------------- Name of toxic substance - #4 Estimated maximum exposure level per shift: Duration of exposure per shift: 19.Describe any special responsibilities you’ll have while using your respirator(s) that may affect the safety and well being of others (e.g. rescue, security) _______________________________________________ ______________________ Employee Signature Date OSHA Mandatory Respirator Medical Evaluation Questionnaire Reviewed by: _______________________________________________ ______________________ PLHCP Signature Date Respirator Medical Clearance Form
Frederick County Fire Fighters

Please check Type(s) of Respirator(s) to be used:

Air Purifying: Atmosphere Supplying:
[ ] Negative Pressure (half face or full face) [ ] Airline (continuous flow)
[ ] PAPR (full face or hood)

Level of Work Effort: [ ] Light [ ] Moderate [ ] Heavy [ ] Strenuous
Extent of Usage:
[ ] On a daily basis
[ ] Occasionally - but more than once a week
[ ] Rarely - or for emergency situations only
Length of Time of Anticipated Effort in Hours: _____________________________
Special Work Considerations: (i.e. high places, temperature, hazardous material,
protective clothing, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________ _____________________________________
Company Safety Representative Telephone Number
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Health Care Provider’s Evaluation
____________________________________________________________________________
Class (check one):
[ ] No restrictions on respirator use
[ ] Some specific use restrictions
[ ] No respirator use permitted
[ ] Need special frames for glasses if required to wear full-face respirator
[ ] No contact lenses
Restrictions:
____________________________________________________________________________
____________________________________________________________________________
[ ] FIT TEST TECHNICIAN HAS CONFIRMED THAT FACIAL HAIR IS NOT PRESENT ACROSS
RESPIRATOR SEAL AREAS AT THE TIME OF TESTING (OSHA REG 29 CFR 1910.134)

________________________________________ ________________________________
Health Care Provider Signature Date

Patient Information CIPRO (ciprofloxacin) ORAL TABLET 500mg Frederick County Health Department: 24-hour Information Telephone Number: 301-600-1029 This drug treats infections. You have been provided a limited supply of medicine. Local emergency health workers or your It belongs to a class of healthcare provider will inform you if you need more medicine after you finish this supply. If so, upon your follow-up visit, you will be told how to get more medicine. You will also be told if no Take this medicine as prescribed. One tablet by mouth, two times a day. You will be provided special dosing instructions for children. Keep taking your medicine, even if you feel okay, unless your doctor tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You should take this medicine with a full glass of water. Drink several glasses of water each day while you are taking this medicine. It is best to take this medicine 2 hours after a meal. If it upsets your stomach, you may take it with food, but do not take it with milk, yogurt, or cheese. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed does. Do not take two doses at the same time. DRUGS AND FOODS TO AVOID: Do not take the following drugs within 2 hours of taking CIPRO: antacids such as Maalox or Mylanta, vitamins, iron supplements, zinc supplements, or sucralfate (Carafate). You may take them 2 hours after or 6 hours before CIPRO. Also, make sure your doctor knows if you are taking asthma medicine like theophylline, gout medicine like probenecid (Benemid), or a blood thinner such as Coumadin. Avoid drinking more than one or two caffeinated beverages (coffee, tea, soft drinks) per day. Avoid taking this medicine with foods containing large amounts of calcium, like milk, yogurt or cheese. WARNINGS: If you have epilepsy or kidney disease, or if you are pregnant, become pregnant, or are breastfeeding, tell emergency healthcare workers before you start ciprofloxacin or other quinolone medicines such as norfloxacin (Norosin), ofloxacin (Floxin) or nalidixic acid (NegGram). This medicine may make you dizzy or lightheaded. Avoid driving or using machinery until you know how it will affect you. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. SIDE EFFECTS: Call you doctor or seek medical advice right away if you are having any of these side effects: rash or hives; swelling of face, throat, or lips; shortness of breath or trouble breathing; seizures; or severe diarrhea. Less serious side effects include nausea, mild diarrhea, stomach pain, dizziness, and headache. Talk with your doctor if you have problems with these side effects. Patient Information DOXYCYCLINE 100MG ORAL TABLET Frederick County Health Department: 24-hour Information Information Telephone Number: 301-600-1029 This drug treats infections. You have been provided a limited supply of medicine. Local emergency health workers or It belongs to a class of your healthcare provider will inform you if you need more medicine after you finish this supply. If so, upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. protection against possible exposure to an infection- Take this medicine as prescribed. One tablet by mouth, two times a day. You will be provided special dosing instructions if you have a child under 8 years of age. Keep taking your medicine, even if you feel okay, unless your healthcare provider tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You may take your medicine with or without food or milk, but food or milk may help you avoid upset stomach. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOOD TO AVOID: Do not take the following medicines within 2 hours of taking DOXYCYCLINE: antacids such as Maalox or Mylanta, calcium or iron supplements, cholestyramine (Questran) or colestipol (Colestid). While you are taking this medicine, birth control pills may not work as well; make sure to use another form of birth control. WARNINGS: If you have liver disease, or if you are or might be pregnant, or if you are breastfeeding, tell emergency healthcare workers before you start taking this medicine. This medicine increases the chance of sunburn; make sure you use sunscreen to protect your skin. Do not take this medicine if you have had an allergic reaction to any tetracycline antibiotics. Women may have vaginal yeast infections from taking this medicine. SIDE EFFECTS: Call you doctor or seek medical attention right away if you are having any of these side effects: skin rash, hives, or itching; wheezing or trouble breathing; swelling of the face, lips, or throat. Less serious side effects include diarrhea, upset stomach, nausea, sore mouth or throat, sensitivity to sunlight, or itching of the mouth or vagina lasting more than 2 days. Talk with your doctor if you have problems with these side effects. Frederick County Health Department, Office of Public Health Preparedness & Response Proposition of Antibiotics Program
Medication Screening, Counseling & Consent Form

Print Name:_____________________________ Date of Birth:______________ Sex: Male___ Female___
Last First
Home Address:____________________________________________________ Home Phone:_______________ Department:_____________________________ Worksite:_______________ Work Phone:_______________ Please answer the following questions carefully and correctly. Do you have an questions that have not been answered? Are you taking any medication? If yes, list medications. Are you allergic to any medications? If yes, specify. Do you have a major medical problem? If yes, specify. Have you ever had or have any of the following medical conditions? If yes, please check all that apply: ___Liver Disease ___Kidney Disease ___Skin Disease If female: Are you pregnant or planning a pregnancy soon? Are you breast-feeding? Are you currently using any form of birth control?
Participant Informed Consent for Prophylaxis medication. I have:
______received information about the medication.
______received participant information packet.
______completed Medication Screening, Counseling and Consent form.
______had the opportunity to have my questions answered.
I have been informed of why I am being screened for this medication, the risks and benefits associated with the
medication, and based on the information provided to me:
______I have decided to participate in this program
______I decline to participate in this program.

I have been informed that I will be given this medication by authority of the Frederick County Health Officer
when the delay required by normal medication dispensing protocols may pose a greater risk to my health and
safety. I agree to take the medication as instructed.

Participant Signature__________________________________ Date_______________________
FOR HEALTH PROFESSIONAL USE ONLY – Circle appropriate medication(s)
Doxycycline Dose: 100mg BID Ciprofloxacin Dose: 500mg BID Health Professional Signature: _________________________________ Date_____________________ Health Professional Name (please print) __________________________________

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