DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility: ________________________________________

Report Year : 2020
Report Month : ___________________

MEDICATIONS GIVEN RECEIVED BY:

(indicate the number of treatment packs dispensed) (Signature over printed
NAME OF GENDER Philhealth No.
name)
PATIENT DIAGNOSIS DATE OF (If PhilHealth
DATE ADDRESS AGE
BIRTH member) Amlodipine Losartan Metoprolol Simvastatin Metformin Gliclazide 30
(Last Name, Family Name,
10 mg, 30 50mg, 30 50mg, 60 20mg, 30 500mg, 90 mg MR, 30
Middle Name) tablet/TP tablets/TP tablets/TP tablets/TP tablets/TP tablets/TP
M F
 MEDICATIONS GIVEN RECEIVED BY:
(indicate the number of treatment packs dispensed) (Signature over printed
NAME OF GENDER Philhealth No.
name)
PATIENT DIAGNOSIS DATE OF (If PhilHealth
DATE ADDRESS AGE
BIRTH member) Amlodipine Losartan Metoprolol Simvastatin Metformin Gliclazide 30
(Last Name, Family Name,
10 mg, 30 50mg, 30 50mg, 60 20mg, 30 500mg, 90 mg MR, 30
Middle Name) tablet/TP tablets/TP tablets/TP tablets/TP tablets/TP tablets/TP
M F
 MEDICATIONS GIVEN RECEIVED BY:
(indicate the number of treatment packs dispensed) (Signature over printed
NAME OF GENDER Philhealth No.
name)
PATIENT DIAGNOSIS DATE OF (If PhilHealth
DATE ADDRESS AGE
BIRTH member) Amlodipine Losartan Metoprolol Simvastatin Metformin Gliclazide 30
(Last Name, Family Name,
10 mg, 30 50mg, 30 50mg, 60 20mg, 30 500mg, 90 mg MR, 30
Middle Name) tablet/TP tablets/TP tablets/TP tablets/TP tablets/TP tablets/TP
M F

Prepared by: Approved by: Received by:

Public Health Pharmacist