ASSIGNMENT 3 – RESEARCH REPORT
Allergies: Physician Name A. Put initials in appropriate box when medication is given. B. Circle initials when not given. C. State reason for refusal / omission on back of form. D. PRN Medications: Reason given and results must be noted on back of form. E. Legend: S = School; H = Home visit; W = Work; P = Program. Phone Number ................
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