NEW MEXICO PHARMACIST NALOXONE PRESCRIPTION PROGRAM REPORTING FORM

NEW MEXICO PHARMACIST NALOXONE PRESCRIPTION PROGRAM REPORTING FORM
For all naloxone prescriptions, please complete Sections I-III below. Only complete Section IV if the patient is getting a refill
or providing information about prior use of naloxone, regardless of where they obtained the naloxone.
DATE______________________ ☐ First Prescription or ☐ Refill (check one)
I. PATIENT INFORMATION____________________________________________________________________________
(1) First letter of legal first name: __
Is your patient Hispanic/Latino? ☐ Yes ☐ No
(2) First two letters of last name: __ __
Is your patient (please check all that apply)?
(3) Date of Birth: (mm/dd): _ _ /_ _
☐ Hispanic/Latino? ☐Black ☐American Indian/Alaskan Native
Naloxone code:__/__/__/__/__/__/__
1 2 2 3 3 3 3
☐Asian/Pacific Islander ☐White ☐Unknown ☐ Other
ZIP code: __ __ __ __ __
Gender: ☐Male ☐Female
II. PHARMACY INFORMATION_________________________________________________________________________
Pharmacy Name:___________________________________
Reason for Naloxone Prescription:
Pharmacy Zip Code: __ __ __ __ __
☐Rx for high-dose opioid
☐Current poly-opioid use
☐Rx for long-term opioid (any ME dose)
☐History of Opioid Abuse
☐Rx for opioid with concurrent benzodiazepine use
☐Patient request for Naloxone
☐Rx for opioid with known/suspected alcohol use
☐Other ___________________________________
III. PRESCRIPTION INFORMATION_(Ask about other drug use to provide prevention education for concurrent drug use)_
Which, if any, of the following drugs does the patient currently use (has used in the past 72 hours)?
☐Alcohol ☐Prescription Painkillers ☐Marijuana ☐Methadone ☐Cocaine ☐Methamphetamine ☐Heroin
☐Benzodiazepines(e.g., Xanax or Valium) ☐ Buprenorphine (e.g., Suboxone) ☐Prescription Sleep Medicine
Naloxone Prescribed by a Pharmacist? ☐ Yes ☐ No Amount prescribed: ______ x 2.0 mg intranasal dosages
IV. USE AND/OR REFILL INFORMATION (Complete only for refills or previous naloxone use)________________________
Was Naloxone administered to a person? ☐Yes ☐No
If no, what happened to the naloxone? (stop after completing this question)
☐lost ☐expired ☐stolen ☐given to a friend or family member ☐other ___________________________
If yes, was it administered to:
☐patient ☐adult family member ☐family member below 18 ☐friend/acquaintance ☐stranger ☐unknown
Date of Naloxone Use: ________(approximate month/year) Amount used:______ x 2.0 mg intranasal dosages
Which of the following drugs were used at time of the overdose? (check all that apply)
☐Alcohol ☐Prescription Painkillers ☐Marijuana ☐Methadone ☐Cocaine ☐Methamphetamine ☐Heroin
☐Benzodiazepines(e.g., Xanax or Valium) ☐ Buprenorphine (e.g., Suboxone) ☐Prescription Sleep Medicine
Did someone do rescue breathing? ☐Yes ☐No ☐Unknown Did someone call 911? ☐Yes ☐No ☐Unknown
What was the outcome? ☐Person OK ☐EMS ☐Emergency Room ☐Hospitalization ☐Deceased
☐Unknown
Please use the Naloxone Cover Sheet & fax completed forms to 505-272-5892