Occupational Health Center
PRESCRIPTION
MRN: EMPLOYEE ID:
PATIENT NAME: FATHER'S NAME:
AGE: y : "Not Available"; ?> Years GENDER:
DEPARTMENT: SECTION:
IN TIME: CLEARANCE TIME:

Weight: kg
Height: cm
BMI:
BP: / mmhg
Pulse: min
Temp: F
SPO2%: %
RBS: mg/dl
FBS: mg/dl
PPBS: mg/dl
Respiratory Rate:
Urine Output:
AVPU:
Trama:
Mobility:
Oxygen Supplementation:
Glasgow coma scale:
GRBS:
BAC Levels:
Total Cholesterol:

Complaints : Diagnosis:
Examination Findings : Body System:
Remarks/Follow-up Investigation Details: Disease Type:
Advices: Chronic Illness:
H/o of Drug Allergy:

Detention Details

Sr Medicine Admin. Route Qty Issued

Rx



Referral: Follow-up date:
Recommended Tests: Recommended Test Parameters:
Doctor Comment: Half Day:
Period Of Rest From: Period Of Rest To:
Fitness Date: Leave Remarks:
Ambulance Out Time: Ambulance In Time:
Treatment from outside or self-treatment: Is Hospitalized





Signature & Stamp


KMC Reg No:

Note:
  • If symptoms persists/Aggravates/worsens Review immediately
  • This medicine has been prescribed for current ailments only.
  • Do not take it more often or for a longer period than advised.
  • If you notice any untoward reaction like skin rash, itching, epigastric burning, or breathlessness - stop taking the medicines and review immediately.
  • Do not share medicines with others without consultation.
  • Avoid self-Medication.
  • Please do not substitute medicines.
Do not Dispense again, unless re-prescribed.
Please bring this prescription with you during your next visit.
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