Name Organization

Address

City State Zip Code

TeWphone Signature of person placing order

Oty. ofCataug Title 50 sheet Cost per ExtendedCode pads pad of 50 Price

PMiO00 Set of 5 Patient Medication Instructions $1.0(includes I pad of each medication)$1.PMIOOI Amoxicillin 4..0_0

PM1001 - ~Patient Medication Instructions 40

PM1002 PhtentoMdiarbionIitalrto 4 .00PM1003 ~~Patient Medication Instructions 40

PM1003 Tlheophyllaine 4 .00Patient Medication Instructions

PMI005 | ~Patient Medication Instructions| T40 |

MM4

Patient Medication Instructions

(Patient Name)

(Date)Phenobarbital is the generic nameof the drug.The brand name of the drug is

The medication should be taken at the following times

The medication should be taken for days.Additional instructions:

_ ~~~~~~~~~~M.D.

The information on this sheet is selective and does not cover all the possible uses, actions, pre-cautions, side effects, or interactions of this drug. For a complete listing of side effects, see themanufacturer's package insert, which can be obtained from your physician or pharmacist~.

American Academy of PediatricsXThis page may be reproduced and used for purposes of education

with credit to American Academy of Pediatrics.

CAmerican Academy of Pediatrics, 1987

PM1002--i

Dear Doctor:The Committee on Drugs of the American Academy of Pediatricsprepared this Patient Medication Instruction Sheet as one of several wehope you find useful to give to a parent when you are writing a prescrip-tion for this drug.

Patient Medication Instructions Sheets are now available for:theophylline, amoxicillin, diphenhtydramine, phenobarbita andcodeine. Each of the patient medi'cation instructions is convenientlyprovided in individual pads of 50 each for $4.00 per pad. Or you canorder a set of all five of the patient medication instructions for $15.00.----------------------------------------------------------

Ordered by: Please print or type AAP Member ID #.

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0)

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Orders under $15.00 must be prepaid.Minimum charge order $15.00.No shipping charges for prepaid orders.Shipping charges will be added to billed orcredit card orders.

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MAIL TO: AAP, Publication Dept, Box 927, Elk Grove Village, IL 60009

Please tell us what other drugs you'd like to have Patient Medication Sheets for.

with this medication. Hyperactivity may occur especially in youngchildren. The drug may cause changes in school performance.Some additional side effects may include

and dry mouth.If there are any problems that may be related to the drug such as

fever, rash or flu-like symptoms, contact your physician orpharmacist.StorageAlways keep this and other medications safely stored and out ofthe reach of small children. Keep the medication in the containerin which it came.Further instructionsDo NOT take other medications without the advice of yourPhlysician.The amount of medication you are to take is

Doctor:

Why this drug is givenThis medication is usually used to prevent recurrence of seizures.How to takeUse this medication exactly as prescribed by your physician. Itmust be taken regularly to be most effective. Take only the amountprescribed, do not take more. If you feel you need more (or less)contact your physician.When to takeTake the medication at the same time(s) each day asrecommended by your physician.How longDo not stop taking this medication without first contacting yourphysician. Always keep an adequate supply on hand; ask yourpharmacist or physician about refills.If yo'u forgetIf a dose is forgotten, take it as soon as remembered. If it is nearor past time for the next dose, take only the scheduled one. Nevertake a double dose to make up for a missed one. Take anyremaining doses for the day at their regularly scheduled times.Common side effectsDrowsiness may occur. This may make driving, bicycle riding,operating machines, reading, mental calculations, or other tasksmore difficult. The sleepiness caused by other drugs such assleeping pills, tranquilizers or alcohol is increased when taken

8 AAP News/July 1987

In submitting these names of board-certified pediatricians to you, it is understood that academic andpediatric credentials are not in question. Comments are requested conoeming possible legal and/or ethicalsituations of which you might have personal knowledge.

DISTRICTI-

MfiIbZChuseftShelly C. Bomstein, M.D.943 Commonwealth he.Newton Center, MA 02159

Myra Ann Citrin, M.D.376 Brown Ave.Sekonk, MA 02771

Paulette Tuerck Gebhardt, M.D.21 BroadwayStoneham, MA 02180

Richard Oliver Heck, M.D.100 Maple Ave.Great Barrington, MA 01230

Rachel F. H.eppen, M.D.16 Smith StreetWestboro, MA 01581

Karen Frances Rothman, M.D.11 Old Nourse StreetWestborough, MA 01581

Margery B. Schonfeld, M.D.500 Salem St.Wilmington, MA 01887

Prince Edward IslandJoan Kathryn Mac Isaac, M.D.Polyclinic Prof. Centre199 Grafton StreetCharlottetown, PE C1A 11L2Canada

Now HampshireCarol Walser Robey, M.D.9 Mendelssohn Lane150 Park St.Hollis, NH 03049

Uniformed Services EastAlan Fetzer Bitner, M.D.USAF Regional Medical CenterWeisbaden, Box 559APO Now York, NY 09220 5300

Wayne Guy Fellmeth, M.D.PSC Box 81APO New York, NY 09289-5360

Drago Tolosa, M .D.9hth Army General Hosp.Box 8APO New York, NY 09757

Marshall LeRoy Upshur, M.D.14814 Darby Dale AveDale City, VA 22193

DISTRICT II

New YorkSusan Fischbeck, M.D.909 West Main StreetRochester, NY 14611

Barbara Ann Heintz, M.D.909 W. Main St.Rochester, NY 14611

Kathleen Ann Stoeckel, M.D.110 Dunham Rd.De Witt, NY 13214

Michael David Terranova, M.D.27 Central AvenueLancaster, NY 14086

New York 2Daryl Renee Altman, M.D.490 Atlantic Ave.Apt. 115East Rockaway, NY 11518

Eric Franklin Gould, M.D.15 Barstow RoadGreat Neck, NY 11021

Jill Susan Hirsch, M.D.Revonah Hill RoadUberty, NY 12754

Susan Soslau Hyman, M.D.15 Barstow RoadGreat Neck, NY 11021

John Charles Maerz Jr, M.D.430 Court St.Utica, NY 13502

Meenaxi V. Sanghani, M.D.901 South Ashland#1501AChicago, IL 606a7

VWane G. Siegel, M.D.1411 Uittle Moose LaneNorthbrook, IL 60062

Sheryl Nannetti Stagl, M.D.220 Country Club DriveProspect Heights, IL 607

Diana Woo, M.D.1406 E. Rochdale PlaceChicago, IL 60615

IowaHolly Hutchison Ardinger, M.D.Div. of Medical GeneticsDept. of PediatricsUniversity of IowaIowa City, IA 52242

KansasGlenn Gordon Hamm, M.D.Bethel Clinic201 S PineNewton, KS 67114

Judy Price Ziegler, M.D.214 N. Old ManorWichita, KS 67208

CPS/AAPLinda Gordon Deonarine, M.D.1206 Rothesay StreetWinnipeg, MB R2G 2M8Canada

MinnesotaJoAnn Johnson, M.D.288 Laurel AvenueSt. Paul, MN 55102

MissouriSusan Elizabeth Homan, M.D.Children's Mercy Hospital24th & Gillham Rd.Kansas City, MO 64108

Karen Jane Oppermann, M.D.4916 Milton CircleIndependence, MO 64055

Janet Mosley Ruzycki, M.D.239 E Swon Ave.St. Louis, MO 63119-3032

WisconsinRegis Richard Chamberlin, M.D.419 Strodman AvenueWisconsin Rapids, WI 54494

Patricia Mary Mc Guire, M.D.#890 Highway 178Chippewa Falls, WI 54729

Surinder Kumar Rajpal, M.D.3004 Stokes LaneManitowoc, WI 54220

DlSTRICT VllAlabamaKarl Emerson Egerman, M.D.Trussville Medical Clinic, P.A.151 Chalkville Rd.Trussville, AL 35173

LouisianaJames Toliver Bennett, M.D.1430 Tulane AvenueNew Orleans, LA 70112

Harley G. Ginsberg, M.D.4016 Lake Villa DriveMetairie, LA 70002 3062

MisssippiDexter Winn Walcott, M.D.304 Dogwood St.Oxford, MS 38656

OklahomaBala Klrishna Venkata Arabolu,

M.D.325 WacoDurant, OK 74701

AAP New/July 1987 9,

Aminerican A6cadenmy of Pediatrics

Door Acdemy Follhw:In order to fuffll the admission requirements of AAP bViw, you are requested to:Carefully rewbw the follaing list of now applicants for AcademyW mem#bership. Relay your reactions directy

to your district chairman (whose name and address are listed at the end of this list).

Donna Esther Wiener, M.D.'16 VUtodfildd Rd.Stwrook, NY 117901112

Now York 3Andra J. Fertig, M.D.412 East 4th StreetBrooklyn, NY 11218

Frances Flug, M.D.New York Univ. Medical Center550 First Ave.New York, NY 10016

Robert John Giusti, M.D.19 Christopher St.New York, NY 10014

Elliot A. Grossman, M.D.1155 Warburton Ave.Apt. 2-FYonkers, NY 10701

Samuel Kwame Mensah; M.D.3234 Olinville AvenueBronx, NY 10467

Anne Terese Nucci, M.D.77 Mace AvenueApt. 5CBronx, NY 10467

Daniel Potaznik, M.D.155 East 76th StreetNew York, NY 10021

Deborah Sue Saltzberg, M.D.1245 Park Ave. Apt. 7-DNew York, NY 10128

.DISTRICTmDistrict of ColumbiaRobert John Buczek, M.D.2227 20th Street N.W.Washington, DC 20009

Krisa Page Van Meurs, M.D.3227 Tennyson Ave. N.W.Washington, DC 20015

MarylandJohn P. Johnson, M.D.655 West Baltimore StreetBaltimore, MD 21201

Robert Bernard Johnston, M.D.602 College AvenueLutherville, MD 21093

Nagji Jadavji Sureja, M.D.Family Medical Center4212- Ridge RoadWestminster, MD 21157

New JerseyHenry H. Bernstein, M.D.71 Lafayette Ln.Cherry Hill, NJ 08003

Cheryl Adele Dickson, M.D.2 Essex Ad.Maplewood, NJ 07040

Maureen Rickerhauser-Krall,M.D.

10 Netherwood CircleEdison, NJ 08820

Gail Schewitz, M.D.704 Palisade AvenueTeaneck, NJ 0i7666

PennsylvaniaHarry J. Bell, M.D.6 Rech AvenueOreland, PA 19075

Karen Jane Benedum, M.D.Mercy Hosp. of PittsburghDept. of Pediatrics1400 Locust StreetPittsburgh, PA 15219

Margaret Ann Bawring, M.D.118 C Montrose Ave.Bryn Maw~r, PA 19010

Kevin Henry Browngoehl, M.D.9 Selwyn DriveBroomall, PA 19008

Susan Miriam Fuchs, M.D.513 Shady henueApt. 31Pifttburgh, PA 15206

Cindy Beth Grossman, D.O.1525 Buck Creek Dr.Yardley, PA 19067

Greta Parhad Iskandrian, M.D.1124 Penshurst LaneNarberth, PA 1907

Lynn Marie Konchanin, M.D.279 Woods Edge PlaceLanghorne, PA 19047

Fredesvinda Suba Luna, M.D.807 Tumpike AvenueClearfield, PA 16830

Naresh S. Maingi, M.D.1520 Pelham RoadHarrisburg, PA 17110

Samuel Kossie Parrish Jr., M.D.922 South 48th StreetPhiladelphia, PA 19143

David A. Piccoli, M.D.Division of Gastroenterology34th and Civic CenterPhiladelphia, PA 19104

Sharon Lee Pilmer, M.D.410 W. Stafford St.Philadelphia, PA 19144

Philip Roth, M.D.509 Ott RoadBala-Cynwyd, PA 19004

Richard Arthur Schwarz, M.D.Courtyard at Oxford ValleySuite 102300 Middletown Blvd.Langhorne, PA 19047

Alison Claire Selbst, M.D.13 W Allens LanePhiladelphia, PA 19119

James Stuart Wright, M.D.312 S 24th St. Apt. 1-BPhiladelphia, PA 19103

DISTRICT IV

Florida|Lori Ann Fein, M.D.9100 S.W. 87th Ave.Miami, FL 33176

Kevin Robert Kowaleski, M.D.9441 Fontainebleau Blvd.Apt 202Miami, FL 33172

Jaime Martinez, M.D.7840 Camino Real #P402Miami, FL 33143

Theo Lassar Meyer, M.D.1830 S Osprey Ave. #108Sarasota, FL 33579

Mark Stephen Rotlewicz, M.D.291 NW 78th Ave.Plantation, FL 33317

Armin Jared Wagman, M.D.Department of PediatricsDiv. of CardiologyBox J-296, JHMHCGainesville, FL 32610

GeorgiaDouglas Lloyd Williams, M.D.4536 Chamblee-Dunwoody Rd.

Suite 201Atlanta, GA 30338

North CarolinaBonnie J. Cameron, M.D.227 Butler CourtChapel Hill, NC 27514

Susan Warren Denfield, M.D.L-3 U oodbridgeCarrboro, NC 27510

Don Clark Steiner, M.D.549 Arbor Hill Rd. Apt 31CKomersville, NC 2728

Puerto RicoIngrid Milagros Marino, M.D.A-7 A*e. Lopategui ParkvilleGuaynabo, PR 00657

South CarolinaStephen Gates Ramsaiy, M.D.Neely Medical BuildingJacobs HighwayClinton, SC 29325

H. Gratin Smith, M.D.I Medical Park, Ste. 104Walterboro, SC 29488

TennesseeBanani Dirghangi, M.D.6614 Prince EdwardMemphis, TN 38119

David Alan Howard, M.D.559 Techno LaneApartment 102Memphis, TN 38105

VirginiaJulita C. Beca, M.D.6505 Bellamine Ct.Mc Lean, VA 22101

Rhoda Leigh Bland Mahoney,M.D.

7113 Three Chopt Rd.Suite 101Richmond, VA 23226

Cynthia Swain, M.D.1011 E. Jefferson StreetCharlottesville, VA 22901

DeAnna Lynne Trail, M.D.880 Kempsville RoadSuite 2000Norfolk, VA 23502-

DISTRICT V

OhioChristopher Warren Clardy, M.D.|433 Collins StreetCincinnati, OH 45202

Steven Elliot Krug, M.D.15610 Van Aken Blvd., Apt.#21Shaker Heights, OH 44120

Baruni M. Samal, M.D.5427 Harleston DriveLyndhurst, OH 44124

CPS/AAPTherese St. Laurent-Gagnon,

M.D.446 Canterbury AvenueOakville, ON L6J 51R7Canada

DISTRICT VI

IllinoisUmapathi Reddi Cattamanchi,

M.D.60 Orland Park DriveOrland Park, IL 60462

Joseph K. Chung, M.D.6515 N. MaplewoodChicago, IL 60645

Renu Jain, M.D.219 Woodglen LaneOak Brook, IL 60521

Kenneth S. Polin, M.D.9129 N. KeelerSkokie, IL 60076

Edith Prichard, M.D.6919 W. BerwynChicago, IL 60656

Sheri Ross Rabins, M.D.1900 Hollister Dr.Suite 270Libertyville, IL 60048

Fredericke I. Cohen, M.D.6565 South Yale Suite 704Tulsa, OK 74136

Donald Ra!y Hamilton, M.D.6160 S. Yale Ave.Tulsa, OK 74136

William Patton Simmons, M.D.1115 East 16th StreetTulsa, OK 74120

TexasPaul Nicholas Grubb, M.D.2137 lEast 22nd StreetBrownsville, TX 78520

Gail Ellen Herman, M.D.2120 El Paseo #2004Houston, TX 77054

Steven Piecuch, M.D.202 MeredithDumas, TX 79029

Cathy Deanne Sandstrom, M.D.155 Robins LaneBrownsville, TX 78520

Penelope E. Terhune, M.D.108003 ShawnbrookHouston, TX 77071

DISTR= Vil

ArizonaCelia Jane Flinn, M.D.1300 N. 12th Street#614Phoenix, AZ 85006

British ColumbiaRoslyn Elizabeth Selby, M.D.7281 Cambie StreetApt. 403Vancouver, BC V6P 3H4Canada

ColoradoDouglas McClain Ford, M.D.8712 W. 75th Pi.Arvada, CO 80005

IdahoTerence Earl Neff, M.D.1106 Ironwood Dr.Coeur D'Alene, ID 83814

New MexicoGary Arnold Escudero, M.D.1904 Mt. ViewGallup, NM 87301

Uniformed Services VestJoan Grobstein, M.D.2215 Rogers WaySanta Rosa, CA 94404

Dale Regis Zimmermann, D.O.6943 Cherry Hill Loop NEAlbuquerque, NM 87111

William S. Bourquard, M.D.12625 W 36th SouthMountain Home, ID 83647

Theodore John Cieslak, M.D.5433 LOOP 205Apt. #255Temple, TX 76502

Diane L. Jordan-Wagner, M.D.4929 Reginald Dr.Wichita Falls, TX 76308

Capt. Carmen Arroyo Otero,M.D.

4827 N. E. Winfield Cr.Lawton, OK 73507

Major Van Emmet Perry, M.D.5019 S. Canyon Rd.Rapid City, SD 57702

UtahRobert E. Shaddy, M.D.Primary Children's Med. Center320 12th AvenueSalt Lake City, UT 84103

Meena Adhar, M.D.9050 E. Shoewo Drive#280Mercer Island, VA 98040

Dale Iris Batlm, M.D.784 14th AvenueLongview, WA M9863

DISTRICT IX

Callfombn iDavid Allan Bennett, M.D.700 West Park Ave.Suite A-1Los Gatos, CA 95030

Patricia Otto Francis, M.D.930 Dewing Ave.Lafayette, CA 94549

Janice Whitman Gilless, M.D.210 San Leandro WaySan Francisco, CA 94127

Douglas Joseph Hamill, M.D.Franciscan School of Theology1712 Euclid Ave.Berkley, CA 94909

Linda C. Wilcox, M.D.3775 St. Peter Ct.Concord, CA 94518

Callfomis 2Richard Kaye Mathis, M.D.2801 Atlantic AvenueLong Beach, CA 90801

Narindar K. Nat, M.D.HMNFMC 27141 Hidaway Ave.Canyon Country, CA 91351

California 3Michael Harvey Mellon, M.D.7060 Clairemont Mesa Blvd.San Diego, CA 92111

Xuanto Nguyen Leduc, M.D.1130 North Boatswain CircleAnaheim, CA 92801

DISTRICT CHAIRMbEN

District IMaurice E. Keenan, M.D.16 Bristol RoadWest Newton, MA 02165

District IIJames G. Lione, M.D.Flushing Hospital and

Medical CenterFlushing, NY 11355

District IIIArthur Maron, M.D.59 Woodland Ave.West Orange, NJ 07052

District IVRobert Grayson, M.D.1185 71st StreetMiami Beach, FL 33141

District VLeonard P. Rome, KA.D.14 Lyman CircleShaker Heights, OH 44122

District VIKenneth O. Johnson, M.D.Milwaukee Medical Clinic3003 W. Good Hope RoadMilwaukee, WI 53217

District VllBetty A. Lowe, M.D.Arkansas Children's Hospital800 MarshallLittle Rock, AR 72202

District VlillDonald W. Schiff, M.D.600 Front Range RoadLitteton, CO 80120

District IXBirt Harvey, M.D.1101 V-ch RoadSuite A1Palo Alto, CA 94303