Organ Prescription

To copy this outline to Microsoft Word, highlight the text and right click.  Hit COPY and then open up your blank document.  Right click again and hit PASTE.  To format it correctly, click on FILE, PAGE SET UP and set your margins to 0.5 on every side of the page.  Now you can type in the information and print it out when you are done.  You can also email it to me at denoc001@hartfordschools.org 

I have a hard copy if you would like to just write it by hand.

 

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: _____________________________