Organ Prescription

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Prescription for (organ name)                                                                    # (on diagram)

Q2. Function:

Q3. Organ system:

Q4. Benefits of this prescription when used with other systems:

Q5. # of Refills:          Explain:

Q6. Side effects of discontinued use:

Q7. Suggestions to increase benefits:

Q7. What to avoid when using:

Q8. Who to call if there are complications:

Q9. Diagnosis and treatment for adverse reactions:

Q10. Serious problems  identified with this prescription:

Physician’s Name ______________________________ Signature: _____________________________