Participant Treatment Sheet

This sheet is to be completed by the prescribing doctor.

Client Name:
Date

Prescribed Medication
(use block letters)

Date of Birth:
Frequency

Name of Doctor:

Dose

Route

(eg. 2 x daily, 4 hourly, 1x3 weekly)

Review
Date

Dose

Route

Circumstances & Frequency

of Administration

Review
Date

Doctor's
Signature

Discontinued
Date
Dr's Signature

Doctor's
Signature

Discontinued
Date
Dr's Signature

PRN and STAT Medication

Date

Prescribed Medication
(use block letters)

Allergies (please print in red)

Doctors Medication Notes

Client Name:
Date

Date of Birth:

Medication

Name of Doctor:

Notes

Upper part of this page to be completed only by doctor

Staff Name

Initials

Staff Name

Initials

Staff Name

Initials

Staff Name

Initials

Staff Name

Initials

Staff Name

Initials

All staff recording the administration of medication on the following sheets MUST print their name and sign their initials in the legend above.