Physician'S Report For Community Care Facilities Page 3
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3PLEASE LIST OVER-THE-COUNTER MEDICATION THAT CAN BE GIVEN TO THE CLIENT/RESIDENT, AS NEEDED,
FOR THE FOLLOWING CONDITIONS:
CONDITIONS
OVER-THE-COUNTER MEDICATION(S)
1.
Headache
_____________________________________
2.
Constipation
_____________________________________
3.
Diarrhea
_____________________________________
4.
Indigestion
_____________________________________
5.
Others (specify condition)
_____________________________________
_________________________________________
_____________________________________
_________________________________________
_____________________________________
_________________________________________
PLEASE LIST CURRENT PRESCRIBED MEDICATIONS THAT ARE BEING TAKEN BY CLIENT/RESIDENT:
1.
________________________________
4.
_______________________________
7.
___________________________
2.
________________________________
5.
_______________________________
8.
___________________________
3.
________________________________
6.
_______________________________
9.
___________________________
PHYSICIAN’S NAME AND ADDRESS:
TELEPHONE:
DATE:
PHYSICIAN’S SIGNATURE
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (TO BE COMPLETED BY PERSON’S AUTHORIZED REPRESENTATIVE)
I hereby authorize the release of medical information contained in this report regarding the physical examination of:
PATIENT’S NAME:
TO (NAME AND ADDRESS OF LICENSING AGENCY):
ADDRESS:
SIGNATURE OF RESIDENT/POTENTIAL RESIDENT AND/OR HIS/HER AUTHORIZED
DATE:
REPRESENTATIVE
LIC 602 (7/11)
PAGE 3 OF 3
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