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