Republic of the Philippines

Province of Agusan del Sur

TALACOGON DISTRICT HOSPITAL
PHIC Accredited Health Care Provider
San Isidro, Talacogon, Agusan del Sur

DISCHARGE

INSTRUCTIONS

Name: _______________________________________________________
Age: _____
Date
Admitted:
__________________
Physician: _____________________________________________________ Sex: _____ Date Discharged:
________________
Discharge
Diagnosis:
____________________________________________________________________________________
____________________________________________________________________________________________________
_
------------------------------------------------------------------------------------------------------------------------------------------------------------------Duration
TIME
DOSAGE

MEDICATION /
TREATMENT

and
FREQUENC
Y

AM
Before
meal

PM
After
meal

Before
meal

NIGHT
After
meal

Before
meal

SPECIAL INSTRUCTIONS:
LABORATORY/XRAY/ULTRASOUND AS OPD (if any):
NEXT CHECK-UP:

After
meal

Bedtime

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!