APPENDIX H ●^587
Are you pregnant or breast feeding?^ Date of last menses^Type of contraception used^
Describe any restrictions/limitations that might interfere with your use of medication for your current problem.
Prescription orders: Patient teaching related to medications prescribed:^ Lab work ordered:
2506_Appendix_H_583-587.indd 587 2506 _AppendixH 583 - 587 .indd 587 Client’s SignatureNurse’s Signature 10/1/10 9:31:02 AM 10 / 1 / 10 9 : 31 : 02 AM