Grampian Naloxone Take Home Programme
Naloxone Training Record
Sex: M
F
Patient Name: ……………………….………………..…….. Date of Birth: …………………………
Address: …………………………………………………………………………………………………...
……………………………………………………………………………………………….……………….
Postcode: ………………………...
Date of Training: ……….………………
Training Service: ….………..……………..…………
Name of Trainer: ……………………………………..……
Name(s) of friends/family members (record in comments section of “consent” tab in NEO)
……..……………………………………………………………………………………………………………
Prison Release date (only if applicable): ……………………………
I consent to:
 Anonymous sharing of data with the NHS for purpose of reporting and research
 the named representatives holding a supply of naloxone on my behalf when they have completed the
appropriate training
Signed (patient): …………………………………………………….
Signed (trainer): …………………………………………………….
Date: ……………………….
Naloxone Supply Record
Declined supply of naloxone?
Yes
No
Date Naloxone kit supplied (if different from above):……………………………..
Batch number: …..……….………..….….. Expiry Date: ………………….….……
Name of Nurse/Pharmacist making supply of naloxone: ………………………………………….
1st supply
Used on self
(Complete reverse)
Used on other
(Complete reverse)
Expired
Lost
Confiscated
Other (please state)……………………………………………………………….……
NB: When inputting data into NEO, if training section only is complete enter up to “Consent” section, save
consent and press close on “Supply” screen
Naloxone Resupply - Kit Used on Someone
When did the overdose occur? (date):………………....
Who administered the kit?:
A Family Member
A friend
Paramedic
By Self to Self
By Self to Another
Other (state)……….…………………………
Where did the overdose occur?:
My own home
Somebody else’s home
Outdoors
Other (state)…………………………………………………………………
Another indoor location
What was the outcome?:
Opioid reversed, person went to hospital
Opioid reversed, person did not go to hospital
Person did not survive
Other……………………………………………………………………………………………………………………….