We plan to open in June 2013! (Our contact information and hours of operation are contained in your packet).

Transcription

1 Northwestern Consolidated Schools of Shelby County, Shelby Eastern Schools Corporation, Southwestern Consolidated School District and Hancock Madison Shelby Education Services benefit eligible employees/dependents: Enclosed please find several important documents pertaining to the Shelby County Schools Health & Wellness Clinic. This is a FREE benefit for all Northwestern Consolidated Schools of Shelby County, Shelby Eastern Schools Corporation, Southwestern Consolidated School District and Hancock Madison Shelby Education Services eligible employees and dependents that are enrolled in the group health plan. We plan to open in June 2013! (Our contact information and hours of operation are contained in your packet). Your packet contains the following documents: 1. General Information Fact Sheet 2. Switch and Save! (generic vs. brand-name prescription options) 3. Magnet with hours of operation and contact information 4. Prescription Drug Formulary list of all FREE medications available through the Clinic. 5. Major Hospital s Notice of Privacy Practices The following documents are also contained in your packet. 6. ACKNOWLEDGMENT of RECEIPT of the NOTICE of PRIVACY PRACTICES 7. AUTHORIZATION TO DISCLOSE HEALTH INFORMATION 8. MEDICAL HISTORY FORM-2 pages Although it is not required, it will definitely save you time and effort to fill out and deliver documents #6, 7 & 8 to a member of the clinic staff in advance of your first clinic visit. If you have more than one eligible person in your household, please make copies of these documents for each eligible family member. NOTE: All health information will be protected in accordance with HIPAA. Alternatively, you can mail your completed forms to: OnSiteSolutions, LLC c/o Major Hospital 150 West Washington Street Shelbyville, IN THANK YOU AND WE LOOK FORWARD TO SEEING YOU IN JUNE!

2 GENERAL INFORMATION Welcome to Shelby County Schools Health and Wellness Clinic (SCSHWC). SCSHWC is an absolutely free (no co-pays and no deductibles) benefit to all benefit eligible Northwestern Consolidated Schools of Shelby County, Shelby Eastern Schools Corporation, Southwestern Consolidated School District and Hancock Madison Shelby Education Services employees, their spouses and their dependent children. You will be eligible to receive free primary care services as well as free medications and prescriptions that are included on the clinic formulary provided in your information packet. SHELBY COUNTY SCHOOLS HEALTH & WELLNESS CLINIC LOCATION SCSHWC is located at the Rampart Professional Building; 30 West Rampart Street, Suite #180, Shelbyville. The Rampart Professional Building is located in front of the Shelby County Athletic Club off State Road 9 (adjacent to McDonalds and Super 8 Motel). James Springer, M.D. MEET OUR MEDICAL DIRECTOR: James Springer, M.D. will oversee the medical care, wellness and disease management services offered by the Clinic. Dr. Springer graduated with his Doctorate in Medicine from American University in 1987 and completed his three-year Practice Medical Residency at Union Hospital in Terre Haute. Dr. Springer has been Board Certified for both adult and pediatric care in California, Oregon and Indiana. He is also a Diplomat at the American Board of Family Practice being Board Certified in the practice of Family Medicine. Dr. Springer has provided Family Practice Medicine since 1991, including seven (7) years in Shelbyville as a practitioner with Shelby County Family Medicine. SCHEDULING You may schedule an appointment Monday-Friday from 7AM-5PM. You are strongly encouraged to call for an appointment at the clinic. Walk-ins will be accepted only if the appointment schedule allows. There will not be an after-hours on-call line. Therefore, if you have a medical emergency and the clinic is not open and you are unable to wait until the clinic opens, please visit your primary care physician, your local urgent care center or call 911.

3 Monday 9:00 a.m. to 1:00 p.m. By telephone: (317) Tuesday 1:00 p.m. to 5:00 p.m. By FAX: (317) Wednesday 8:00 a.m. to 12:00 p.m. Thursday 1:00 p.m. to 5:00 p.m. MedWorks Pharmacy fax: (317) Fri/Sat/Sun CLOSED PHARMACY & PRESCRIPTION REFILLS Please refer to the formulary handout for a list of all available medications offered through SCSHWC and MedWorks Pharmacy. For all other medications and prescriptions, please either (1) talk to your primary care physician about switching your brand-name medication to a generic that is listed on the formulary or (2) continue to have your prescription filled through your pharmacy benefits manager (PBM) under your health insurance plan. Please refer to the sheet entitled Switch and Save! included in your packet for a list of brand-name medications that have generic drugs which are therapeutically equivalent. All medications dispensed or prescriptions filled or refilled by SCSHWC or MedWorks Pharmacy will be strictly limited to formulary items. We will not dispense any narcotics at SCSHWC. Please call (317) for all your prescription needs. For prescriptions originating from a SCSHWC provider: For those medications that are on the formulary and in stock, your SCSHWC provider will dispense your prescription(s) during your visit. If the medication is not in stock during your visit, you may choose to have the medication delivered to SCSHWC by the end of the next day that the clinic is open for business or you may choose to pickup your prescription at MedWorks Pharmacy between the hours of 9:00AM- 5:00PM, Monday through Friday or 9AM-2PM on Saturdays; located at 1424 S. Miller St, Shelbyville (adjacent to former Western Supermarket building). All medications will be delivered to SCSHWC unless you direct otherwise. For prescriptions originating from a licensed provider other than an SCSHWC provider: SCSHWC, through MedWorks Pharmacy, will dispense, fill and/or refill formulary prescriptions written by a licensed provider only at MedWorks Pharmacy between the hours of 9:00AM- 5:00PM, Monday through Friday or 9AM-2PM on Saturdays. Please have your primary care physician fax your prescription information to (317) PLEASE PROVIDE THE CLINIC WITH NO LESS THAN 48-HOURS NOTICE FOR ALL YOUR PRESCRIPTION NEEDS!! LABORATORY SCSHWC will also have laboratory services available during clinic hours.

4 SMOKING CESSATION SCSHWC will offer a smoking cessation program. Please discuss kicking that habit with our providers. By participating in the smoking cessation program you will learn how to break down your smoking triggers and overcome your nicotine addiction. You will also learn how to escape the cycle of quitting and then slipping up and smoking again. You will receive helpful tips, new smoking cessation methods, and the latest information that will help you quit smoking forever. We have smoking cessation prescriptions that will be available to you for free, if you participate in the smoking cessation program. OTHER BENEFITS Mammograms: SCSHWC will offer vouchers upon request for annual screening mammograms for all City health plan participants and their dependents. Asthma Program: SCSHWC will offer to all Hoosier Heartland School Trust & South Central Indiana School Trust health plan participants and their dependents access to an asthma education program administered by Major Hospital s Registered Respiratory Therapist. There will be more information available to you at the clinic regarding Lifestyle Management Programs, Disease Management Programs. Please come in and see us to learn more.

5 Shelby County Schools Formulary Item # GENERIC NAME TRADE NAME Group Class 2081 HYDROXYZINE HCL 25MG ATARAX 25MG Allergy Antihistamine 2082 IBUPROFEN 800MG MOTRIN 800MG Analgesic Analgesic - NSAID 2107 MELOXICAM 15MG MOBIC 15MG Analgesic Analgesic - NSAID 2106 MELOXICAM 7.5MG MOBIC 7.5MG Analgesic Analgesic - NSAID 2119 NAPROXEN 500MG NAPROSYN 500MG Analgesic Analgesic - NSAID TRAMADOL/ACETAMINOPHEN * ULTRACET Analgesic Analgesic Combination TRAMADOL 50MG * ULTRAM 50MG Analgesic Analgesic Non-narcotic 2118 METRONIDAZOLE 500MG FLAGYL 500MG Anti-infective A/B Antibiotic 2064 FLUCONAZOLE 150MG DIFLUCAN 150MG Anti-infective A/B Anti-fungal 2043 CEPHALEXIN 250MG/5ML SUSP KEFLEX Anti-infective A/B Cephalosporin 1st gen 2044 CEPHALEXIN 500MG KEFLEX 500MG Anti-infective A/B Cephalosporin 1st gen 2042 CEFUROXIME 500MG CEFTIN Anti-infective A/B Cephalosporin 2nd gen 2039 CEFDINIR 125MG/5ML SUSP OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2040 CEFDINIR 250MG/5ML SUSP OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2041 CEFDINIR 300MG OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2025 AZITHROMYCIN 100MG/5ML SUSP ZITHROMAX 100MG/5ML SUSP Anti-infective A/B Macrolide 2026 AZITHROMYCIN 200MG/5ML SUSP ZITHROMAX 200MG/5ML SUSP Anti-infective A/B Macrolide 2027 AZITHROMYCIN 250MG Z-PACK (ZITHROMAX) Anti-infective A/B Macrolide 2052 CLARITHROMYCIN 500MG BIAXIN 500MG Anti-infective A/B Macrolide 2011 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 SUSP Anti-infective A/B Penicillin 2012 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 SUSP Anti-infective A/B Penicillin 2013 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 Anti-infective A/B Penicillin 2014 AMOX/ POT CLAVULANATE AUGMENTIN 500MG Anti-infective A/B Penicillin 2015 AMOX/ POT CLAVULANATE AUGMENTIN 875MG Anti-infective A/B Penicillin 2016 AMOXICILLIN 250/5 SUSP AMOXIL 250/5 Anti-infective A/B Penicillin 2017 AMOXICILLIN 400/5 SUSP AMOXIL 400/5 Anti-infective A/B Penicillin 2018 AMOXICILLIN 500MG AMOXIL 500MG Anti-infective A/B Penicillin 2019 AMOXICILLIN 875MG AMOXIL 875MG Anti-infective A/B Penicillin 2049 CIPROFLOXACIN 500MG CIPRO 500MG Anti-infective A/B Quinolone LEVOFLOXACIN 250MG * LEVAQUIN 250MG Anti-infective A/B Quinolone LEVOFLOXACIN 500MG * LEVAQUIN 500MG Anti-infective A/B Quinolone LEVOFLOXACIN 750MG * LEVAQUIN 750MG Anti-infective A/B Quinolone SULFAMETHOXAZOLE/TMP /5ML SEPTRA, BACTRIM SUSP Anti-infective A/B Sulfa 2152 SULFAMETHOXAZOLE/TMP DS SEPTRA DS, BACTRIM DS Anti-infective A/B Sulfa 2062 DOXYCYCLINE 100MG VIBRAMYCIN 100MG Anti-infective A/B Tetracycline MUPIROCIN OINTMENT * BACTROBAN OINTMENT Anti-infective A/B Topical 2120 NITROFURANTOIN MACRO 100MG MACROBID 100MG Anti-infective A/B Urinary atibiotic 2167 NEO/POLY/HC OTIC SOLN CORTISPORIN OTIC SOLN Anti-infective Otic 2131 PHENAZOPYRIDINE 200MG PYRIDIUM 200MG Anti-infective Urinary analgesic ATORVASTATIN 10MG * LIPITOR 10MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 20MG * LIPITOR 20MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 40MG * LIPITOR 40MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 80MG * LIPITOR 80MG Cardiovascular Anti-hyperlipidemic 2074 GEMFIBROZIL 600MG LOPID 600MG Cardiovascular Anti-hyperlipidemic 2104 LOVASTATIN 20MG MEVACOR 20MG Cardiovascular Anti-hyperlipidemic 2105 LOVASTATIN 40MG MEVACOR 40MG Cardiovascular Anti-hyperlipidemic 2137 PRAVASTATIN 20MG PRAVACHOL 20MG Cardiovascular Anti-hyperlipidemic 2138 PRAVASTATIN 40MG PRAVACHOL 40MG Cardiovascular Anti-hyperlipidemic 2186 PRAVASTATIN 80MG TAB PRAVACHOL 80MG Cardiovascular Anti-hyperlipidemic 2146 SIMVASTATIN 20MG ZOCOR 20MG Cardiovascular Anti-hyperlipidemic 2147 SIMVASTATIN 40MG ZOCOR 40MG Cardiovascular Anti-hyperlipidemic 2148 SIMVASTATIN 80MG ZOCOR 80MG Cardiovascular Anti-hyperlipidemic 2205 CLOPIDOGREL 75MG PLAVIX Cardiovascular Antiplatelet 2030 BENAZEPRIL 10MG LOTENSIN 10MG Cardiovascular B/P ACE Inhibitor 2031 BENAZEPRIL 20MG LOTENSIN 20MG Cardiovascular B/P ACE Inhibitor 2095 LISINOPRIL 10MG PRINIVIL - ZESTRIL 10MG Cardiovascular B/P ACE Inhibitor 2096 LISINOPRIL 20MG PRINIVIL - ZESTRIL 20MG Cardiovascular B/P ACE Inhibitor 2097 LISINOPRIL 40MG PRINIVIL - ZESTRIL 40MG Cardiovascular B/P ACE Inhibitor 2098 LISINOPRIL 5MG PRINIVIL-ZESTRIL Cardiovascular B/P ACE Inhibitor 2061 DOXAZOSIN 4MG CARDURA 4MG Cardiovascular B/P Alpha-1 adrenergic blocker IRBESARTAN 150MG * AVAPRO 150MG Cardiovascular B/P Angiotensin II Receptor Antagonist IRBESARTAN 75MG * AVAPRO 75MG Cardiovascular B/P Angiotensin II Receptor Antagonist IRBESARTAN/HCTZ 150/12.5MG * AVALIDE 150/12.5MG Cardiovascular B/P Angiotensin II Receptor Antagonist

6 2180 LOSARTAN 100MG TABS COZAAR 100MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2178 LOSARTAN 25MG TABS COZAAR 25MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2179 LOSARTAN 50MG TABS COZAAR 50MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2053 CLONIDINE 0.1MG CATAPRES Cardiovascular B/P Anti-adrenergic 2020 ATENOLOL 100MG TENORMIN 100MG Cardiovascular B/P Beta-blocker 2021 ATENOLOL 25MG TENORMIN 25MG Cardiovascular B/P Beta-blocker 2022 ATENOLOL 50MG TENORMIN 50MG Cardiovascular B/P Beta-blocker 2115 METOPROLOL 100MG LOPRESSOR 100MG cardiovascular B/P Beta-blocker 2116 METOPROLOL 25MG LOPRESSOR 25MG cardiovascular B/P Beta-blocker 2117 METOPROLOL 50MG LOPRESSOR 50MG cardiovascular B/P Beta-blocker 2156 METOPROLOL ER 100MG TOPROL XL 100MG cardiovascular B/P Beta-blocker 2134 METOPROLOL ER 25MG TOPROL XL 25MG cardiovascular B/P Beta-blocker 2135 METOPROLOL ER 50MG TOPROL XL 50MG cardiovascular B/P Beta-blocker 2009 AMLODIPINE 10MG NORVASC 10MG Cardiovascular B/P Calcium channel blocker 2010 AMLODIPINE 5MG NORVASC 5MG Cardiovascular B/P Calcium channel blocker 2174 DILTIAZEM CD 120MG CARDIZEM CD 120MG Cardiovascular B/P Calcium channel blocker DILTIAZEM CD 180MG * CARDIZEM CD 180MG Cardiovascular B/P Calcium channel blocker 2058 DILTIAZEM CD 240MG CARDIZEM CD 240MG Cardiovascular B/P Calcium channel blocker 2059 DILTIAZEM ONCE DAILY 360MG TIAZAC 360MG Cardiovascular B/P Calcium channel blocker 2165 VERAPAMIL SR 180MG CALAN SR 180MG Cardiovascular B/P Calcium channel blocker 2166 VERAPAMIL SR 240MG CALAN SR 240MG Cardiovascular B/P Calcium channel blocker AMLODIPINE/BENAZEPRIL 10/20MG TAB * LOTREL 10/20 Cardiovascular B/P Combination 2168 AMLODIPINE/BENAZEPRIL 5/10MG TAB LOTREL 5/10 Cardiovascular B/P Combination ATENOLOL/CHLORTHALIDONE 100/25 * TENORETIC 100 Cardiovascular B/P Combination 2024 ATENOLOL/CHLORTHALIDONE 50/25 TENORETIC 50 Cardiovascular B/P Combination BENAZEPRIL/HCTZ LOTENSIN/HCTZ Cardiovascular B/P Combination 2032 BENAZEPRIL/HCTZ LOTENSIN/HCTZ cardiovascular B/P Combination BISOPROLOL/HCTZ * ZIAC Cardiovascular B/P Combination 2035 BISOPROLOL/HCTZ ZIAC Cardiovascular B/P Combination 2099 LISINOPRIL/HCTZ 10/12.5 PRINZIDE - ZESTORETIC 10/12.5 cardiovascular B/P Combination 2100 LISINOPRIL/HCTZ 20/12.5 PRINZIDE - ZESTORETIC 20/12.5 cardiovascular B/P Combination 2101 LISINOPRIL/HCTZ 20/25 PRINZIDE - ZESTORETIC 20/25 cardiovascular B/P Combination 2181 LOSARTAN/HCTZ 50/12.5MG TAB HYZAAR 50/12.5MG Cardiovascular B/P Combination SPIRONOLACTONE/HCTZ 25/25 * ALDACTAZIDE 25/25 Cardiovascular B/P Combination 2191 TRIAMTERENE 37.5/HCTZ 25 TABS MAXZIDE 37.5/25 Cardiovascular B/P Combination 2163 TRIAMTERENE 75/HCTZ 50 TABS MAXZIDE 75/50 Cardiovascular B/P Combination 2006 AMIODARONE 200MG CORDARONE 200MG Cardiovascular Cardiac Anti-arrhythmic 2056 DIGOXIN LANOXIN 0.125MG Cardiovascular Cardiac glycoside 2069 FUROSEMIDE 20MG LASIX 20MG Cardiovascular Diuretic 2070 FUROSEMIDE 40MG LASIX 40MG Cardiovascular Diuretic 2079 HYDROCHLOROTHIAZIDE 25MG HYDRODIURIL 25MG Cardiovascular Diuretic 2080 HYDROCHLOROTHIAZIDE 50MG HYDRODIURIL 50MG Cardiovascular Diuretic 2149 SPIRONOLACTONE 25MG ALDACTONE 25MG Cardiovascular Diuretic 2151 SPIRONONLACTONE 50MG ALDACTONE 50MG Cardiovascular Diuretic 2071 GABAPENTIN 300MG NEURONTIN 300MG CNS Anti-convulsant 2072 GABAPENTIN 400MG NEURONTIN 400MG CNS Anti-convulsant 2073 GABAPENTIN 600MG NEURONTIN 600MG CNS Anti-convulsant 2175 GABAPENTIN 800MG TAB NEURONTIN 800MG CNS Anti-convulsant 2189 TOPIRAMATE 25MG TAB TOPAMAX 25MG CNS Anti-convulsant 2190 TOPIRAMATE 50MG TAB TOPAMAX 50MG CNS Anti-convulsant 2172 BUPROPION XL 150MG (ONCE DAILY) WELLBUTRIN XL 150mg CNS Antidepressant 2142 PROMETHAZINE 25MG PHENERGAN 25MG CNS Anti-nausea CARBIDOPA-LEVODOPA 25/100 * SINEMET CNS Anti-parkinsons 2033 BENZONATATE 100MG CAPSULES TESSALON PERLES 100MG Cough/cold Cough Suppressant 2075 GLIMEPIRIDE 2MG AMARYL 2MG Diabetes Diabetes 2076 GLIMEPIRIDE 4MG AMARYL 4MG Diabetes Diabetes 2077 GLYBURIDE/METFORMIN 2.5/500 GLUCOVANCE 2.5/500 Diabetes Diabetes 2078 GLYBURIDE/METFORMIN 5/500 GLUCOVANCE 5/500 Diabetes Diabetes 2108 METFORMIN 1000MG GLUCOPHAGE 1000MG Diabetes Diabetes 2109 METFORMIN 500MG GLUCOPHAGE 500MG Diabetes Diabetes 2110 METFORMIN 500MG ER GLUCOPHAGE XR 500MG Diabetes Diabetes 2111 METFORMIN 850MG GLUCOPHAGE 850MG Diabetes Diabetes METFORMIN ER 750MG * GLUCOPHAGE XR 750MG Diabetes Diabetes PIOGLITAZONE 15MG TAB ACTOS 15MG Diabetes Diabetes PIOGLITAZONE 30MG TAB ACTOS 30MG Diabetes Diabetes PIOGLITAZONE 45MG TAB ACTOS 45MG Diabetes Diabetes

7 2114 METHYLPREDNISOLONE 4MG DOSEPACK MEDROL 4MG DOSPAK Endocrine Steroid PREDNISOLONE ORAL SOLN 15MG/5ML * PRELONE Endocrine Steroid 2139 PREDNISONE 10MG DELTASONE 10MG Endocrine Steroid 2140 PREDNISONE 20MG DELTASONE 20MG Endocrine Steroid 2141 PREDNISONE 50MG TABLET DELTASONE 50MG TABLET Endocrine Steroid 2084 LEVOTHYROXINE 100 MCG SYNTHROID 0.100MG Endocrine Thyroid 2085 LEVOTHYROXINE 112 MCG SYNTHROID 0.112MG Endocrine Thyroid 2086 LEVOTHYROXINE 125 MCG SYNTHROID 0.125MG Endocrine Thyroid 2087 LEVOTHYROXINE 137 MCG SYNTHROID 0.137MG Endocrine Thyroid 2088 LEVOTHYROXINE 150 MCG SYNTHROID 0.150MG Endocrine Thyroid 2089 LEVOTHYROXINE 175 MCG SYNTHROID 0.175MG Endocrine Thyroid 2090 LEVOTHYROXINE 200 MCG SYNTHROID 0.200MG Endocrine Thyroid 2091 LEVOTHYROXINE 25 MCG SYNTHROID 0.025MG Endocrine Thyroid 2092 LEVOTHYROXINE 50 MCG SYNTHROID 0.05MG Endocrine Thyroid 2093 LEVOTHYROXINE 75 MCG SYNTHROID 0.075MG Endocrine Thyroid 2094 LEVOTHYROXINE 88 MCG SYNTHROID 0.088MG Endocrine Thyroid 2143 RANITIDINE 150MG ZANTAC 150MG gastrointestinal GI H2 Antagonist 2133 POLYETHYLENE GLYCOL MIRALAX/GLYCOLAX gastrointestinal GI Laxative 2187 SUCRALFATE 1GM TABS CARAFATE 1GM gastrointestinal GI Protective 2177 LANSOPRAZOLE 30MG CAP * PREVACID 30MG gastrointestinal GI Proton Pump Inhibitor 2182 METOPROLOL ER 200MG TAB * TOPROL XL 200MG gastrointestinal GI Proton Pump Inhibitor 2126 OMEPRAZOLE 20MG PRILOSEC 20MG (Rx) gastrointestinal GI Proton Pump Inhibitor 2185 PANTOPRAZOLE 40MG TAB * PROTONIX 40MG gastrointestinal GI Proton Pump Inhibitor 2188 TAMSULOSIN 0.4MG CAP FLOMAX 0.4MG Genitourinary BPH Agent 2000 ALENDRONATE 70MG WEEKLY PACK FOSAMAX 70MG WEEKLY Metabolic Osteoporosis METHOTREXATE 2.5MG * METHOTREXATE 2.5MG Misc Anti-arthritic 2005 ALLOPURINOL 300MG ZYLOPRIM 300MG Misc Uricosuric 2055 CYCLOBENZAPRINE 10MG FLEXERIL 10MG neuro-musular Muscle Relaxant 2028 BACLOFEN 10MG LIORESAL 10MG neuro-musular Muscle Relaxant/Antispasmodic 2184 ORPHENADRINE ER 100MG TAB NORFLEX 100MG neuro-musular Muscle Relaxant/Antispasmodic 2155 TIZANIDINE 4MG ZANAFLEX 4MG neuro-musular Muscle Relaxant/Antispasmodic 2068 FOLIC ACID 1MG FOLIC ACID 1MG nutritional Hematinic 2136 POTASSIUM CL 20MEQ ER TABLETS K-DUR 20MEQ nutritional Potassium Supplement AMITRIPTYLINE 100MG * ELAVIL 100MG Psych Antidepressant 2008 AMITRIPTYLINE 25MG ELAVIL 25MG Psych Antidepressant 2036 BUPROPION SR 150MG WELLBUTRIN SR 150 Psych Antidepressant 2037 BUPROPION XL 300MG WELLBUTRIN XL 300 Psych Antidepressant 2050 CITALOPRAM 20MG CELEXA 20MG Psych Antidepressant 2051 CITALOPRAM 40MG CELEXA 40MG Psych Antidepressant ESCITALOPRAM 10MG * LEXAPRO 10MG Psych Antidepressant ESCITALOPRAM 20MG * LEXAPRO 20MG Psych Antidepressant 2066 FLUOXETINE 20MG PROZAC 20MG Psych Antidepressant 2128 PAROXETINE 10MG PAXIL 10MG Psych Antidepressant 2129 PAROXETINE 20MG PAXIL 20MG Psych Antidepressant 2130 PAROXETINE 30MG PAXIL 30MG Psych Antidepressant 2144 SERTRALINE 100MG ZOLOFT 100MG Psych Antidepressant 2145 SERTRALINE 50MG ZOLOFT 50MG Psych Antidepressant 2160 TRAZODONE 100MG DESYREL 100MG Psych Antidepressant 2161 TRAZODONE 50MG DESYREL 50MG Psych Antidepressant 2194 VENLAFAXINE XR 150MG CAP * EFFEXOR XR 100MG Psych Antidepressant 2192 VENLAFAXINE XR 37.5MG CAP * EFFEXOR XR 37.5MG Psych Antidepressant 2193 VENLAFAXINE XR 75MG CAP * EFFEXOR XR 75MG Psych Antidepressant 2003 ALBUTEROL UNIT DOSE VENTOLIN, PROVENTIL Respiratory Bronchodilator 2176 IPRATROPIUM ALBUTEROL INH SOLN DUONEB Respiratory Bronchodilator 2207 MONTELUKAST 10MG SINGULAIR 10MG Respiratory Misc 2206 MONTELUKAST 4MG CHEWABLE SINGULAIR 4MG CGEWABLE Respiratory Misc MONTELUKAST 5MG CHEWABLE* SINGULAIR 5MG CHEWABLE Respiratory Misc 2067 FLUTICASONE NASAL SPRAY FLONASE NASAL SPRAY Topical Nasal Steroid 2170 ANTIPYRENE/BENZOCAINE OTIC SOLN AURALGAN Topical Otic Analgesia 2054 CLOTRIMAZOLE-BETAMETHASONE CRM LOTRISONE CREAM Topical Topical Combination 2065 FLUOCINONIDE CREAM 0.05% LIDEX CREAM Topical Topical Steroid

8 Shelby County Schools Formulary Item # GENERIC NAME TRADE NAME Group Class 2003 ALBUTEROL UNIT DOSE VENTOLIN, PROVENTIL Respiratory Bronchodilator 2000 ALENDRONATE 70MG WEEKLY PACK FOSAMAX 70MG WEEKLY Metabolic Osteoporosis 2005 ALLOPURINOL 300MG ZYLOPRIM 300MG Misc Uricosuric 2006 AMIODARONE 200MG CORDARONE 200MG Cardiovascular Cardiac Anti-arrhythmic AMITRIPTYLINE 100MG * ELAVIL 100MG Psych Antidepressant 2008 AMITRIPTYLINE 25MG ELAVIL 25MG Psych Antidepressant 2009 AMLODIPINE 10MG NORVASC 10MG Cardiovascular B/P Calcium channel blocker 2010 AMLODIPINE 5MG NORVASC 5MG Cardiovascular B/P Calcium channel blocker AMLODIPINE/BENAZEPRIL 10/20MG TAB * LOTREL 10/20 Cardiovascular B/P Combination 2168 AMLODIPINE/BENAZEPRIL 5/10MG TAB LOTREL 5/10 Cardiovascular B/P Combination 2011 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 SUSP Anti-infective A/B Penicillin 2012 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 SUSP Anti-infective A/B Penicillin 2013 AMOX TR-POT CLAV /5 SUSP AUGMENTIN /5 Anti-infective A/B Penicillin 2014 AMOX/ POT CLAVULANATE AUGMENTIN 500MG Anti-infective A/B Penicillin 2015 AMOX/ POT CLAVULANATE AUGMENTIN 875MG Anti-infective A/B Penicillin 2016 AMOXICILLIN 250/5 SUSP AMOXIL 250/5 Anti-infective A/B Penicillin 2017 AMOXICILLIN 400/5 SUSP AMOXIL 400/5 Anti-infective A/B Penicillin 2018 AMOXICILLIN 500MG AMOXIL 500MG Anti-infective A/B Penicillin 2019 AMOXICILLIN 875MG AMOXIL 875MG Anti-infective A/B Penicillin 2170 ANTIPYRENE/BENZOCAINE OTIC SOLN AURALGAN Topical Otic Analgesia 2020 ATENOLOL 100MG TENORMIN 100MG Cardiovascular B/P Beta-blocker 2021 ATENOLOL 25MG TENORMIN 25MG Cardiovascular B/P Beta-blocker 2022 ATENOLOL 50MG TENORMIN 50MG Cardiovascular B/P Beta-blocker ATENOLOL/CHLORTHALIDONE 100/25 * TENORETIC 100 Cardiovascular B/P Combination 2024 ATENOLOL/CHLORTHALIDONE 50/25 TENORETIC 50 Cardiovascular B/P Combination ATORVASTATIN 10MG * LIPITOR 10MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 20MG * LIPITOR 20MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 40MG * LIPITOR 40MG Cardiovascular Anti-hyperlipidemic ATORVASTATIN 80MG * LIPITOR 80MG Cardiovascular Anti-hyperlipidemic 2025 AZITHROMYCIN 100MG/5ML SUSP ZITHROMAX 100MG/5ML SUSP Anti-infective A/B Macrolide 2026 AZITHROMYCIN 200MG/5ML SUSP ZITHROMAX 200MG/5ML SUSP Anti-infective A/B Macrolide 2027 AZITHROMYCIN 250MG Z-PACK (ZITHROMAX) Anti-infective A/B Macrolide 2028 BACLOFEN 10MG LIORESAL 10MG neuro-musular Muscle Relaxant/Antispasmodic 2030 BENAZEPRIL 10MG LOTENSIN 10MG Cardiovascular B/P ACE Inhibitor 2031 BENAZEPRIL 20MG LOTENSIN 20MG Cardiovascular B/P ACE Inhibitor BENAZEPRIL/HCTZ LOTENSIN/HCTZ Cardiovascular B/P Combination 2032 BENAZEPRIL/HCTZ LOTENSIN/HCTZ cardiovascular B/P Combination 2033 BENZONATATE 100MG CAPSULES TESSALON PERLES 100MG Cough/cold Cough Suppressant BISOPROLOL/HCTZ * ZIAC Cardiovascular B/P Combination 2035 BISOPROLOL/HCTZ ZIAC Cardiovascular B/P Combination 2036 BUPROPION SR 150MG WELLBUTRIN SR 150 Psych Antidepressant 2172 BUPROPION XL 150MG (ONCE DAILY) WELLBUTRIN XL 150mg CNS Antidepressant 2037 BUPROPION XL 300MG WELLBUTRIN XL 300 Psych Antidepressant CARBIDOPA-LEVODOPA 25/100 * SINEMET CNS Anti-parkinsons 2039 CEFDINIR 125MG/5ML SUSP OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2040 CEFDINIR 250MG/5ML SUSP OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2041 CEFDINIR 300MG OMNICEF Anti-infective A/B Cephalosporin 3rd gen 2042 CEFUROXIME 500MG CEFTIN Anti-infective A/B Cephalosporin 2nd gen 2043 CEPHALEXIN 250MG/5ML SUSP KEFLEX Anti-infective A/B Cephalosporin 1st gen 2044 CEPHALEXIN 500MG KEFLEX 500MG Anti-infective A/B Cephalosporin 1st gen 2049 CIPROFLOXACIN 500MG CIPRO 500MG Anti-infective A/B Quinolone 2050 CITALOPRAM 20MG CELEXA 20MG Psych Antidepressant 2051 CITALOPRAM 40MG CELEXA 40MG Psych Antidepressant 2052 CLARITHROMYCIN 500MG BIAXIN 500MG Anti-infective A/B Macrolide 2053 CLONIDINE 0.1MG CATAPRES Cardiovascular B/P Anti-adrenergic 2205 CLOPIDOGREL 75MG PLAVIX Cardiovascular Antiplatelet 2054 CLOTRIMAZOLE-BETAMETHASONE CRM LOTRISONE CREAM Topical Topical Combination 2055 CYCLOBENZAPRINE 10MG FLEXERIL 10MG neuro-musular Muscle Relaxant 2056 DIGOXIN LANOXIN 0.125MG Cardiovascular Cardiac glycoside 2174 DILTIAZEM CD 120MG CARDIZEM CD 120MG Cardiovascular B/P Calcium channel blocker DILTIAZEM CD 180MG * CARDIZEM CD 180MG Cardiovascular B/P Calcium channel blocker 2058 DILTIAZEM CD 240MG CARDIZEM CD 240MG Cardiovascular B/P Calcium channel blocker 2059 DILTIAZEM ONCE DAILY 360MG TIAZAC 360MG Cardiovascular B/P Calcium channel blocker

9 2061 DOXAZOSIN 4MG CARDURA 4MG Cardiovascular B/P Alpha-1 adrenergic blocker 2062 DOXYCYCLINE 100MG VIBRAMYCIN 100MG Anti-infective A/B Tetracycline ESCITALOPRAM 10MG * LEXAPRO 10MG Psych Antidepressant ESCITALOPRAM 20MG * LEXAPRO 20MG Psych Antidepressant 2064 FLUCONAZOLE 150MG DIFLUCAN 150MG Anti-infective A/B Anti-fungal 2065 FLUOCINONIDE CREAM 0.05% LIDEX CREAM Topical Topical Steroid 2066 FLUOXETINE 20MG PROZAC 20MG Psych Antidepressant 2067 FLUTICASONE NASAL SPRAY FLONASE NASAL SPRAY Topical Nasal Steroid 2068 FOLIC ACID 1MG FOLIC ACID 1MG nutritional Hematinic 2069 FUROSEMIDE 20MG LASIX 20MG Cardiovascular Diuretic 2070 FUROSEMIDE 40MG LASIX 40MG Cardiovascular Diuretic 2071 GABAPENTIN 300MG NEURONTIN 300MG CNS Anti-convulsant 2072 GABAPENTIN 400MG NEURONTIN 400MG CNS Anti-convulsant 2073 GABAPENTIN 600MG NEURONTIN 600MG CNS Anti-convulsant 2175 GABAPENTIN 800MG TAB NEURONTIN 800MG CNS Anti-convulsant 2074 GEMFIBROZIL 600MG LOPID 600MG Cardiovascular Anti-hyperlipidemic 2075 GLIMEPIRIDE 2MG AMARYL 2MG Diabetes Diabetes 2076 GLIMEPIRIDE 4MG AMARYL 4MG Diabetes Diabetes 2077 GLYBURIDE/METFORMIN 2.5/500 GLUCOVANCE 2.5/500 Diabetes Diabetes 2078 GLYBURIDE/METFORMIN 5/500 GLUCOVANCE 5/500 Diabetes Diabetes 2079 HYDROCHLOROTHIAZIDE 25MG HYDRODIURIL 25MG Cardiovascular Diuretic 2080 HYDROCHLOROTHIAZIDE 50MG HYDRODIURIL 50MG Cardiovascular Diuretic 2081 HYDROXYZINE HCL 25MG ATARAX 25MG Allergy Antihistamine 2082 IBUPROFEN 800MG MOTRIN 800MG Analgesic Analgesic - NSAID 2176 IPRATROPIUM ALBUTEROL INH SOLN DUONEB Respiratory Bronchodilator IRBESARTAN 150MG * AVAPRO 150MG Cardiovascular B/P Angiotensin II Receptor Antagonist IRBESARTAN 75MG * AVAPRO 75MG Cardiovascular B/P Angiotensin II Receptor Antagonist IRBESARTAN/HCTZ 150/12.5MG * AVALIDE 150/12.5MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2177 LANSOPRAZOLE 30MG CAP * PREVACID 30MG gastrointestinal GI Proton Pump Inhibitor LEVOFLOXACIN 250MG * LEVAQUIN 250MG Anti-infective A/B Quinolone LEVOFLOXACIN 500MG * LEVAQUIN 500MG Anti-infective A/B Quinolone LEVOFLOXACIN 750MG * LEVAQUIN 750MG Anti-infective A/B Quinolone 2084 LEVOTHYROXINE 100 MCG SYNTHROID 0.100MG Endocrine Thyroid 2085 LEVOTHYROXINE 112 MCG SYNTHROID 0.112MG Endocrine Thyroid 2086 LEVOTHYROXINE 125 MCG SYNTHROID 0.125MG Endocrine Thyroid 2087 LEVOTHYROXINE 137 MCG SYNTHROID 0.137MG Endocrine Thyroid 2088 LEVOTHYROXINE 150 MCG SYNTHROID 0.150MG Endocrine Thyroid 2089 LEVOTHYROXINE 175 MCG SYNTHROID 0.175MG Endocrine Thyroid 2090 LEVOTHYROXINE 200 MCG SYNTHROID 0.200MG Endocrine Thyroid 2091 LEVOTHYROXINE 25 MCG SYNTHROID 0.025MG Endocrine Thyroid 2092 LEVOTHYROXINE 50 MCG SYNTHROID 0.05MG Endocrine Thyroid 2093 LEVOTHYROXINE 75 MCG SYNTHROID 0.075MG Endocrine Thyroid 2094 LEVOTHYROXINE 88 MCG SYNTHROID 0.088MG Endocrine Thyroid 2095 LISINOPRIL 10MG PRINIVIL - ZESTRIL 10MG Cardiovascular B/P ACE Inhibitor 2096 LISINOPRIL 20MG PRINIVIL - ZESTRIL 20MG Cardiovascular B/P ACE Inhibitor 2097 LISINOPRIL 40MG PRINIVIL - ZESTRIL 40MG Cardiovascular B/P ACE Inhibitor 2098 LISINOPRIL 5MG PRINIVIL-ZESTRIL Cardiovascular B/P ACE Inhibitor 2099 LISINOPRIL/HCTZ 10/12.5 PRINZIDE - ZESTORETIC 10/12.5 cardiovascular B/P Combination 2100 LISINOPRIL/HCTZ 20/12.5 PRINZIDE - ZESTORETIC 20/12.5 cardiovascular B/P Combination 2101 LISINOPRIL/HCTZ 20/25 PRINZIDE - ZESTORETIC 20/25 cardiovascular B/P Combination 2180 LOSARTAN 100MG TABS COZAAR 100MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2178 LOSARTAN 25MG TABS COZAAR 25MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2179 LOSARTAN 50MG TABS COZAAR 50MG Cardiovascular B/P Angiotensin II Receptor Antagonist 2181 LOSARTAN/HCTZ 50/12.5MG TAB HYZAAR 50/12.5MG Cardiovascular B/P Combination 2104 LOVASTATIN 20MG MEVACOR 20MG Cardiovascular Anti-hyperlipidemic 2105 LOVASTATIN 40MG MEVACOR 40MG Cardiovascular Anti-hyperlipidemic 2107 MELOXICAM 15MG MOBIC 15MG Analgesic Analgesic - NSAID 2106 MELOXICAM 7.5MG MOBIC 7.5MG Analgesic Analgesic - NSAID 2108 METFORMIN 1000MG GLUCOPHAGE 1000MG Diabetes Diabetes 2109 METFORMIN 500MG GLUCOPHAGE 500MG Diabetes Diabetes 2110 METFORMIN 500MG ER GLUCOPHAGE XR 500MG Diabetes Diabetes 2111 METFORMIN 850MG GLUCOPHAGE 850MG Diabetes Diabetes METFORMIN ER 750MG * GLUCOPHAGE XR 750MG Diabetes Diabetes METHOTREXATE 2.5MG * METHOTREXATE 2.5MG Misc Anti-arthritic 2114 METHYLPREDNISOLONE 4MG DOSEPACK MEDROL 4MG DOSPAK Endocrine Steroid 2115 METOPROLOL 100MG LOPRESSOR 100MG cardiovascular B/P Beta-blocker

10 2116 METOPROLOL 25MG LOPRESSOR 25MG cardiovascular B/P Beta-blocker 2117 METOPROLOL 50MG LOPRESSOR 50MG cardiovascular B/P Beta-blocker 2156 METOPROLOL ER 100MG TOPROL XL 100MG cardiovascular B/P Beta-blocker 2182 METOPROLOL ER 200MG TAB * TOPROL XL 200MG gastrointestinal GI Proton Pump Inhibitor 2134 METOPROLOL ER 25MG TOPROL XL 25MG cardiovascular B/P Beta-blocker 2135 METOPROLOL ER 50MG TOPROL XL 50MG cardiovascular B/P Beta-blocker 2118 METRONIDAZOLE 500MG FLAGYL 500MG Anti-infective A/B Antibiotic 2207 MONTELUKAST 10MG SINGULAIR 10MG Respiratory Misc 2206 MONTELUKAST 4MG CHEWABLE SINGULAIR 4MG CGEWABLE Respiratory Misc MONTELUKAST 5MG CHEWABLE* SINGULAIR 5MG CHEWABLE Respiratory Misc MUPIROCIN OINTMENT * BACTROBAN OINTMENT Anti-infective A/B Topical 2119 NAPROXEN 500MG NAPROSYN 500MG Analgesic Analgesic - NSAID 2167 NEO/POLY/HC OTIC SOLN CORTISPORIN OTIC SOLN Anti-infective Otic 2120 NITROFURANTOIN MACRO 100MG MACROBID 100MG Anti-infective A/B Urinary atibiotic 2126 OMEPRAZOLE 20MG PRILOSEC 20MG (Rx) gastrointestinal GI Proton Pump Inhibitor 2184 ORPHENADRINE ER 100MG TAB NORFLEX 100MG neuro-musular Muscle Relaxant/Antispasmodic 2185 PANTOPRAZOLE 40MG TAB * PROTONIX 40MG gastrointestinal GI Proton Pump Inhibitor 2128 PAROXETINE 10MG PAXIL 10MG Psych Antidepressant 2129 PAROXETINE 20MG PAXIL 20MG Psych Antidepressant 2130 PAROXETINE 30MG PAXIL 30MG Psych Antidepressant 2131 PHENAZOPYRIDINE 200MG PYRIDIUM 200MG Anti-infective Urinary analgesic PIOGLITAZONE 15MG TAB ACTOS 15MG Diabetes Diabetes PIOGLITAZONE 30MG TAB ACTOS 30MG Diabetes Diabetes PIOGLITAZONE 45MG TAB ACTOS 45MG Diabetes Diabetes 2133 POLYETHYLENE GLYCOL MIRALAX/GLYCOLAX gastrointestinal GI Laxative 2136 POTASSIUM CL 20MEQ ER TABLETS K-DUR 20MEQ nutritional Potassium Supplement 2137 PRAVASTATIN 20MG PRAVACHOL 20MG Cardiovascular Anti-hyperlipidemic 2138 PRAVASTATIN 40MG PRAVACHOL 40MG Cardiovascular Anti-hyperlipidemic 2186 PRAVASTATIN 80MG TAB PRAVACHOL 80MG Cardiovascular Anti-hyperlipidemic PREDNISOLONE ORAL SOLN 15MG/5ML * PRELONE Endocrine Steroid 2139 PREDNISONE 10MG DELTASONE 10MG Endocrine Steroid 2140 PREDNISONE 20MG DELTASONE 20MG Endocrine Steroid 2141 PREDNISONE 50MG TABLET DELTASONE 50MG TABLET Endocrine Steroid 2142 PROMETHAZINE 25MG PHENERGAN 25MG CNS Anti-nausea 2143 RANITIDINE 150MG ZANTAC 150MG gastrointestinal GI H2 Antagonist 2144 SERTRALINE 100MG ZOLOFT 100MG Psych Antidepressant 2145 SERTRALINE 50MG ZOLOFT 50MG Psych Antidepressant 2146 SIMVASTATIN 20MG ZOCOR 20MG Cardiovascular Anti-hyperlipidemic 2147 SIMVASTATIN 40MG ZOCOR 40MG Cardiovascular Anti-hyperlipidemic 2148 SIMVASTATIN 80MG ZOCOR 80MG Cardiovascular Anti-hyperlipidemic 2149 SPIRONOLACTONE 25MG ALDACTONE 25MG Cardiovascular Diuretic SPIRONOLACTONE/HCTZ 25/25 * ALDACTAZIDE 25/25 Cardiovascular B/P Combination 2151 SPIRONONLACTONE 50MG ALDACTONE 50MG Cardiovascular Diuretic 2187 SUCRALFATE 1GM TABS CARAFATE 1GM gastrointestinal GI Protective SULFAMETHOXAZOLE/TMP /5ML SEPTRA, BACTRIM SUSP Anti-infective A/B Sulfa 2152 SULFAMETHOXAZOLE/TMP DS SEPTRA DS, BACTRIM DS Anti-infective A/B Sulfa 2188 TAMSULOSIN 0.4MG CAP FLOMAX 0.4MG Genitourinary BPH Agent 2155 TIZANIDINE 4MG ZANAFLEX 4MG neuro-musular Muscle Relaxant/Antispasmodic 2189 TOPIRAMATE 25MG TAB TOPAMAX 25MG CNS Anti-convulsant 2190 TOPIRAMATE 50MG TAB TOPAMAX 50MG CNS Anti-convulsant TRAMADOL 50MG * ULTRAM 50MG Analgesic Analgesic Non-narcotic TRAMADOL/ACETAMINOPHEN * ULTRACET Analgesic Analgesic Combination 2160 TRAZODONE 100MG DESYREL 100MG Psych Antidepressant 2161 TRAZODONE 50MG DESYREL 50MG Psych Antidepressant 2191 TRIAMTERENE 37.5/HCTZ 25 TABS MAXZIDE 37.5/25 Cardiovascular B/P Combination 2163 TRIAMTERENE 75/HCTZ 50 TABS MAXZIDE 75/50 Cardiovascular B/P Combination 2194 VENLAFAXINE XR 150MG CAP * EFFEXOR XR 100MG Psych Antidepressant 2192 VENLAFAXINE XR 37.5MG CAP * EFFEXOR XR 37.5MG Psych Antidepressant 2193 VENLAFAXINE XR 75MG CAP * EFFEXOR XR 75MG Psych Antidepressant 2165 VERAPAMIL SR 180MG CALAN SR 180MG Cardiovascular B/P Calcium channel blocker 2166 VERAPAMIL SR 240MG CALAN SR 240MG Cardiovascular B/P Calcium channel blocker

11 Mailing Address: Shelby County Schools Health & Wellness Clinic Physical Location: Rampart Professional Building c/o Major Hospital 30 West Rampart, Ste. # W. Washington Shelbyville, Indiana Shelbyville, Indiana Phone Phone FAX: PATIENT NAME: MEDICAL HISTORY page 1 of 2 Physician Section: I have reviewed and updated this patient history. DATE PROVIDER SIGNATURE DATE PROVIDER SIGNATURE DATE PROVIDER SIGNATURE Today s Date: Referred By: Age: Height: Feet Date Complaint/Problem Started: Problem Area of Body: Describe Your Chief Complaint(s): Weight: Inches How much pain are you having? Pain Scale 1 10 (with 10 as the highest): Sex: Male Female Drug Allergies: None Codeine Morphine Penicillin Sulfa Other Antibiotics Other Drug or Medicine, Please List: Allergic to: None Adhesives Contrast Dye Food Latex Nail Polish/Cosmetic Nuts/Peanuts Seafood Other, Please List: Current Medications including herbs and/or supplements: I do not take prescription medicines. 1. Drug Drug Dose: Frequency: Reason taking drug: 2. Drug Drug Dose: Frequency: Reason taking drug: 3. Drug Drug Dose Frequency: Reason taking drug: 4. Drug Drug Dose Frequency: Reason taking drug: 5. Drug Drug Dose Frequency: Reason taking drug: 6. Drug Drug Dose Frequency: Reason taking drug: 7. Drug Drug Dose Frequency: Reason taking drug: 8. Drug Drug Dose Frequency: Reason taking drug: 9. Drug Drug Dose Frequency: Reason taking drug: 10. Drug Drug Dose: Frequency: Reason taking drug: Preferred Pharmacy: City: SHELBY COUNTY SCHOOL CLINIC 001

12 Mailing Address: Shelby County Schools Health & Wellness Clinic Physical Location: Rampart Professional Building c/o Major Hospital 30 West Rampart, Ste. # W. Washington Shelbyville, Indiana Shelbyville, Indiana Phone Phone FAX: MEDICAL HISTORY - page 2 of 2 PAST SURGICAL HISTORY FAMILY HISTORY SOCIAL HISTORY I have never had surgery. Yes No Is your mother living? Marital Status/Living Arrangements: Yes No Is your father living? Yes No Are you married? Yes No Appendix removed. How may brothers do you have? Yes No Do you live alone? If Yes No Colon removed. Yes No Are all brothers alive? No, who do you live with? Yes No Gall Bladder removed. How many sisters do you have? Yes No Hernia repaired. Yes No Are all sisters alive? Yes No Kidney removed. Yes No Do you have Yes No Thyroid removed. children? Yes No Tonsils removed. Children s Age(s) and Name(s): Yes No Uterus, ovaries, or breast removed. Other surgery, please indicate below: 1. Surgery: Year: 2. Surgery: Year: 3. Surgery: Year: 4. Surgery: Year: 5. Surgery: Year: 6. Surgery: Year: 7. Surgery: Year: 8. Surgery: Year: 9. Surgery: Year: Please indicate which of your blood relatives (M=Mother, F=Father, S=Sister, B=Brother) have/had the following health problems: None of these problems in my family. Alcoholism Allergies Anemia Arthritis Asthma Bleeds easily Cancer Diabetes Emphysema Epilepsy Glaucoma Heart Disease High Blood Pressure High Cholesterol Kidney Disease Leukemia Liver Disease Mental Illness Migraines Stomach Ulcer Stroke Suicide Tuberculosis Other disease, please describe below: Highest Education Level Completed: College High School Elementary School Yes No Are you employed? Where do you work: Yes No Do you smoke? If Yes, what do you smoke: Pack(s)/Day Number of Years Yes No Do you drink alcoholic beverages each day? If Yes, what do you drink? How much do you drink each day? 10. Surgery: Year: Yes No Do you use recreational drugs? Yes No diet? Are you on a special If Yes, describe diet: SHELBY COUNTY SCHOOL CLINIC 001

13 Mailing Address: Shelby County Schools Health & Wellness Clinic Physical Location: Rampart Professional Building c/o Major Hospital 30 West Rampart, Ste. # W. Washington Shelbyville, Indiana Shelbyville, Indiana Phone Phone FAX: AUTHORIZATION TO DISCLOSE HEALTH INFORMATION I,, give my consent for Shelby County Schools Health & Wellness Clinic to release medical and billing information to the following person(s): I also understand that it is my responsibility to notify Shelby County Schools Health & Wellness Clinic of any changes to this authorization. This authorization is valid indefinitely unless we receive written notification of requested changes. I give Shelby County Schools Health & Wellness Clinic permission to leave messages regarding my test results, appointment reminders, and any other information pertaining to my medical record on/with: Voice Mail Answering Machine Family Member Other Signature of Patient, Parent, or Legal Guardian Date Printed Name of Patient, Parent, or Legal Guardian Date Signature of Witness from Shelby County Schools Health & Wellness Clinic Date SHELBY COUNTY SCHOOL CLINIC 003

14 Mailing Address: Shelby County Schools Health & Wellness Clinic Physical Location: Rampart Professional Building c/o Major Hospital 30 West Rampart, Ste. # W. Washington Shelbyville, Indiana Shelbyville, Indiana Phone Phone FAX: English Version ACKNOWLEDGMENT of RECEIPT of the NOTICE of PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. ACKNOWLEDGEMENT OF RECEIPT My signature acknowledges my receipt of the Notice of Privacy Practice s related to the use and disclosure of my health information. Signature of Patient or Legal Representative Date Spanish Version Esta Noticia describe como la informacion medica sobre usted podria ser usada y revelada y como usted puede tener acceso a esta informacion. Por favor revisela cuidadoasamente. ACUSE DE RECIBO Con mi firma reconozco que he recibido la Noticia de la Privacidad de la Practica, relacionada al uso y revelacion de la informacion sobre mi salud. Firma del Paciente/Representante Legal Fecha COUNTY SCHOOL CLINIC 002

15 Switch and Save! Many brand-name medications have generic drugs that are therapeutically equivalent. However, these substitutions require your physicia and may not be appropriate in every case. If you take one of the drugs in the left column, ask your doctor if one of the drugs in the right co would be appropriate for you. If it is, you may get that drug free at the Shelby County Schools Health & Wellness Clinic. Ask your doctor. If you take Accolate Aciphex Altace Avodart Benicar, Benicar HCT Boniva Bystolic Celebrex Clarinex Crestor Cymbalta Cymbalta (continued) Dexilant Diovan Diovan HCT Humalog Levemir Nasacort AQ Nasonex Nexium Paxil CR Pepcid (famotidine) Pristiq Proair HFA Synthroid Uloric Xopenex Xyzal Zebeta Ask your doctor if you can try one of these Shelby County Schools Health & Wellness Clinic Formulary alternativ Montelukast (Singulair) 10mg, 4mg, 5mg Omeprazole (Prilosec) 20mg, Pantoprazole (Protonix) 40mg, Lansoprazole (Prevacid) Lisinopril (Prinivil, Zestril) 5mg, 10mg, 20mg, 40mg, Benazapril (Lotensin) 10mg, 20mg Tamsulosin (Flomax) Losartan (Cozaar) 50mg, 100mg; Irbesartan (Avapro) 75mg, 150mg; Losartan/HCTZ (Hyzaar), Irbesartan/HCTZ Alendronate (Foxamax) Metoprolol (Lopressor), Metoprolol ER (Toprol XL), Atenolol (Tenormin) Meloxicam (Mobic) 7.5mg, 15mg, Naproxen 500mg Loratadine (Claritin) 10mg Simvastatin (Zocor) 20mg, 40mg, 80mg, Pravastatin (Pravachol) 40mg, Lovastatin (Mevacor) 20mg, 40mg, Atorv Citalopram (Celexa) 20mg, 40mg, Fluoxetine (Prozac) 20mg, Sertraline (Zoloft) 50mg, 100mg, Paroxetine (Paxil Venlafaxine ER (Effexor XR) 37.5 mg, 75mg, 150mg; Escitaloprm (Lexapro) 10mg, 20mg Omeprazole (Prilosec) 20mg, Pantoprazole (Protonix) 40mg, Lansoprazole (Prevacid) Losartan (Cozaar) 50mg, 100mg; Irbesartan (Avapro) 75mg, 150mg Losartan/HCTZ (Hyzaar), Irbesartan/HCTZ (Avalide) Novolog Lantus Fluticasone (Flonase) Fluticasone (Flonase) Omeprazole (Prilosec) 20mg, Pantoprazole (Protonix) 40mg Paroxetine (Paxil) 10mg, 20mg, 30mg Ranitidine (Zantac) 150mg Venlafaxine ER (Effexor XR) 37.5 mg, 75mg, 150mg; Escitaloprm (Lexapro) 10mg, 20mg Ventolin (albuterol) HFA Levothyroxine (Synthroid) (all common strengths) Allopurinol (Zyloprim) 300mg Albuterol Loratadine (Claritin) 10mg, Cetirizine (Zyrtec) 10mg, Fexofenadine (Allegra) 180mg Metoprolol (Lopressor), Metoprolol ER (Toprol XL), Atenolol (Tenormin)

16 oval e) (Lipitor) 20mg, 30mg