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Doh Maintenance Form

This document is a maintenance medicines utilization report from a health facility in the Philippines for 2018. It contains patient information including name, age, sex, address, and PhilHealth number. It also lists the medications dispensed to each patient including the number of treatment packs of amlodipine, losartan, metoprolol, simvastatin, metformin, and gliclazide. The report must be signed by both the preparer and approver before it is received.

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Seriel Tismo
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878 views2 pages

Doh Maintenance Form

This document is a maintenance medicines utilization report from a health facility in the Philippines for 2018. It contains patient information including name, age, sex, address, and PhilHealth number. It also lists the medications dispensed to each patient including the number of treatment packs of amlodipine, losartan, metoprolol, simvastatin, metformin, and gliclazide. The report must be signed by both the preparer and approver before it is received.

Uploaded by

Seriel Tismo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Republic of the Philippines

DEPARTMENT OF HEALTH
OFFICE OF THE SECRETARY
 

DOH MAINTENANCE MEDICINES UTILIZATION REPORT


Name of Health Facility_________________________________________
Report Year: 2018
Report Month:___________

SEX MEDICATION GIVEN


NAME OF PATIENT ( DATE OF ( indicate the number of treatment packs dispensed ) RECEIVED BY:
DATE Last Name, Fmily Name, Middle ADDRESS AGE Philhealth No. ( Signature over printed
BIRTH Gliclazide 30 name)
Name ) M F Amlodipine 10mg 30 Losartan 50 mg 30 Metropolol 50 mg, 60 Simvastatin 10 mg, Metformin 500mg,
mg,MR, 30
tablet/ TP tablets/TP tablets/TP 30 tablets/ TP 90 tablets/TP
tablest/TP
SEX MEDICATION GIVEN
NAME OF PATIENT ( indicate the number of treatment packs dispensed ) RECEIVED BY:
DATE OF
DATE ( Last Name, Fmily Name, Middle ADDRESS AGE Philhealth No. Gliclazide 30 ( Signature over
BIRTH M F Amlodipine 10mg 30 Losartan 50 mg 30 Metropolol 50 mg, 60 Simvastatin 10 mg, Metformin 500mg,
Name ) tablet/ TP tablets/TP tablets/TP 30 tablets/ TP 90 tablets/TP
mg,MR, 30
tablest/TP
printed name)

Prepared by: Approved by: Received by:

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