Naloxone Administration Report Form If you are a human and are seeing this field, please leave it blank. Date: Time of Incident: Staff Name: Location: Name of Subject (if available): Age of Subject: Signs of Overdose present: (check all that apply) UnresponsiveBreathing SlowlyNot BreathingBlue LipsSlow PulseNo PulseOther If other, please describe: Overdose on what drugs? (check all that apply) HeroinAlcoholMethadoneBenzos/BarbituatesCocaine/CrackSuboxoneAny other opiodUnknownOther If other, please describe: Amount/doses of Intranasal Naloxone used: How long to take effect? Less than 1 minute1-3 minutes3-5 minutes< 5 minutesDon't know Subject's Response: Responsive & AlertResponsive & SedatedNo response Subject's Post-Intranasal Naloxone withdrawal symptoms: (check all that apply) NoneVomitingIrritable/AngryCombativeNauseousMuscle AchesRunny NoseOther If other, please describe: Other Actions Taken:(check all that apply) Sternal RubAEDRecovery PositionBystander Intranasal NaloxoneRescue BreathingOxygenChest compressionsOther If other, please describe: Transferred to Hospital: Name of Ambulance Service: Notes/Comments/Follow Up:
