Scheme for Strengthening of Drug De-Addiction Services, Ministry of Health & Family Welfare, Government of India

CLIENT DOSE SHEET FOR OPIOID SUBSTITUTION THERAPY

Name of the Patient: Tick the appropriate medicine:

1 BUPRENORPHINE (0.4 mg & 2mg)

OST Regn. No / ID:
2 BUPRENORPHINE-NALOXONE (2mg/0.5mg)
Date of OST initiation:
3 METHADONE (5mg/ml)
Month & Year of Dispensing:

Current Dose: Next Follow-up due:

Day Buprenorphine Buprenorphine Buprenorphine- Methadone Total dose Signature of Nurse

0.4mg 2mg Naloxone (2/0.5) (5mg/ml) consumed / Pharmacist

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

National Drug Dependence Treatment Centre, AIIMS, New Delhi

DTC-FF-07
 Scheme for Strengthening of Drug De-Addiction Services, Ministry of Health & Family Welfare, Government of India

Day Buprenorphine Buprenorphine Buprenorphine- Methadone Total dose Signature of Nurse

0.4mg 2mg Naloxone (2/0.5) (5mg/ml) consumed / Pharmacist
13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

National Drug Dependence Treatment Centre, AIIMS, New Delhi

DTC-FF-07