MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Monthly Medical Log
Month:	Year:
Foster Youth:	DCN:
Resource Parent(s):	DVN:
Complete for all events during the month identified – Policy 4.4.3 * Use additional page, if necessary
Child’s Current Weight:	Date Weight was taken:
PHYSICIAN VISIT
Date	Name / Clinic Address / Contact Info	Purpose of Visit	Current Medication Change Including Dosages	New Medication Prescribed Including Dosages	Other (Including adverse reaction to medications
MEDICAL EVENT
Date	Medical Event	Treatment	Outcome	Any medical event not covered by a physician’s visit (Stomachache, sick from school, etc.)
THERAPIST VISIT
Date	Name & Address / Contact Info	Purpose of Visit
INFORMED CONSENT DECISIONS
Date	Treatment, Medication, etc for which consent was given	By Whom
UPCOMING APPOINTMENTS
Date	Name & Address / Contact Info	Purpose of Visit
MEDICATION LIST – List all medications administered (prescribed and OTC) inclusive of all changes noted in Physician Visit Section.
Medication Name	Dosage (strength & frequency)	Reason for Taking	Prescriber
LIST MISSED/CANCELED APPOINTMENTS
Date	Physician/Therapist Name	Reason Why Missed/Canceled	Rescheduled Date