Republic of the PhilippinesProvince of Agusan del Sur

TALACOGON DISTRICT HOSPITALPHIC Accredited Health Care ProviderSan Isidro, Talacogon, Agusan del Sur

D I S C H A R G E I N S T R U C T I O N S

Name: _______________________________________________________ Age: _____ Date Admitted: __________________Physician: _____________________________________________________ Sex: _____ Date Discharged: ________________Discharge Diagnosis: _________________________________________________________________________________________________________________________________________________________________________________________

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MEDICATION / TREATMENT

DOSAGE and

FREQUENCY

TIMEDurationAM PM NIGHT

BedtimeBefore meal

After meal

Before meal

After meal

Before meal

After meal

SPECIAL INSTRUCTIONS:

LABORATORY/XRAY/ULTRASOUND AS OPD (if any):

NEXT CHECK-UP:

RECEIVED BY (Printed name and Signature): RELATIONSHIP TO PATIENT:

PREPARED BY (Printed name and Signature):

NOTE: PLEASE DO NOT FORGET TO BRING THIS FORM ON YOUR FOLLOW-UP CHECK-UP. THANK YOU!