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DHHS 2802 (Revised 07/04)
PHNPD (Review 07/07) Page _____
16. Pharmacy Name /Telephone Number
1.
First Name
Last Name
MI
2. Patient Number --
H
3. Date of Birth
Month Day Year
4. Race
□
1. White
□
2. Black/African American
□
3. American Indian/Alaska Native
□
4. Asian
□
5. Native Hawaiian/Other Pacific Islander
□
6. Other
Ethnicity: Hispanic/Latino Origin?
□
Yes
□
No
5. Gender
1. Male
2. Female
6. County of Residence
8. Date
(M/D/Y)
9. /\ or DC
Date
(M/D/Y)
10. Medication Name
11. Lot No./
Manufacturer
12. Dose/ Rte./Frequency
13. Pt. Med Ed.
(Source with Date)
14. Prescriber’s
Name
15. Signature
7. Allergies
1.__________________________________
2.__________________________________
3.__________________________________
4.__________________________________
5.___________________________________
NC Department of Health and Human Services
Public Health Nursing and Professional Development
Medication Flow Sheet