Name

Age

Date of Birth

Medical record number

23 hr observation

Name of attending physician

Phone number of attending physician

Intractable Headache Contributing Diagnoses

Condition

Allergies

Regular, but no caffeine

Acitivity

Notify MD for: T > 100, P < 60 or > 120, BP < 90/60 or > 170/110

No analgesics

No narcotics

Reglan 10 mg IV followed by DHE 0.5 mg IV

Then every 8 hrs give Reglan 10 mg IV followed by DHE 1 mg IV until patient is 100% HA free X 24-48 hrs (HA scores = 0)

Other

If Other, please specify

Heplock

Hemogram

basal metabolic profile

Signature

Print Name

Date and Time