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 4.24.2 * Use additional page, if necessary
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
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 (prescribed and OTC), current as of last day of the month, inclusive of all changes noted in Physician Visit Section.
Medication Name	Dosage (strength & frequency)	Reason for Taking	Prescriber