SHORT PRESCRIPTIONS

Respiratory System
ACUTE ATTACK OF BRONCHIAL
ASTHMA
 ACUTE ATTACK OF BRONCHIAL ASTHMA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address: ___________________________ Contacts: ____________
Prescription Serial Number____________ Date:________
Patient’s full Name: ______________________________________________
Patient`s Address and Phone number: ___________________________
Sex____ Age____ Weight_____

Rx
Salbutamol Metered Dose Inhaler (100 microgram/
puff ).
send one such inhaler.
Take 2 -4 initial puffs, Then 1-2 puffs every 10-20 mins.
Visit the doctor after 7 days for checkup and refill of
prescription.

Doctor’s signature &

CHRONIC BRONCHIAL ASTHMA
 CHRONIC BRONCHIAL ASTHMA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address: ___________________________ Contacts: _____________
Prescription Serial Number:____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number:___________________________
Sex____ Age____ Weight_____

Rx
Budenoside metered dose inhaler
Send one such inhaler
Take 2 puffs 2 times a day.

Doctor’s signature
& date
Doctors stamp
Cardiovascular system
MILD HYPERTENTION
 MILD HYPERTENTION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address: ___________________________ Contacts: _______________
Prescription Serial Number_______________________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number:___________________________
Sex____ Age____ Weight_____

Rx
Tab. Hydrochlorthiazide 25 mg
Send such 7 tablets
Take one tablet daily in the morning.
OR
Tab. Atenolol 25 mg.
Send such 7 tablets.
Take one tablet daily in the morning.
Visit the doctor after 7 days to adjust the dose, for
checkup and to refill the prescription.
Doctor`s signature & date
Doctors stamp
HYPERTENSIVE CRISIS
 HYPERTENSIVE CRISIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address:___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Inj. Sodium Nitroprusside 50 mg/ml vial
Send such 2 vials
Administer slowly as continuous intravenous drip
with close monitoring in 5% dextrose adjusting the
dose to 0.5mg/kg/min.

Doctor’s signature
& date
ACUTE ATTACK OF ANGINA
PECTORIS
 ACUTE ATTACK OF ANGINA PECTORIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Nitroglycerine 0.5mg
Send such four tablets
Keep one tablet below the tongue repeat the dose if
required, after 15 min.
Spit out the tablet once relief is obtained.

Doctor’s signature
& date
Doctors stamp
Haemopoietic system
MICROCYTIC HYPOCHORMIC ANEMIA
 MICROCYTIC HYPOCHORMIC ANEMIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Ferrous sulphate 200mg
Send such 21 tablets
Take one tab. 3 times a day after food.

Doctor’s signature
& date
PERNICIOUS ANEMIA
 PERNICIOUS ANEMIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Inj. Cyanocobalamine 500 microgram/ml, 5ml vial
Send such 3 vials
Inject 100 mcg/day for 10 days followed by 100 mcg
weekly and then monthly for maintenance.

Doctor’s signature
& date
Megaloblastic anemia due to
folate deficiency
 Megaloblastic anemia due to folate
deficiency
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Folic acid 5 mg
Send such 7 tablets
Take one tablet daily.

Doctor’s signature
& date
Autocoids/NSAIDS/ANS/CNS
FEVER
 FEVER
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Paracetamol 500 mg.
Send such 9 tablets.
Take one tab. 3 times a day till fever subsides.

Doctor’s signature
& date
HEADACHE
 HEADACHE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Paracetamol 500 mg
Send such 9 tablets
Take one tab. 3 times a day for 3 day.

Doctor’s signature
& date
Doctors stamp
Motion sickness
 Motion sickness
Tab. Promethazine 25 mg (dose 25-50
mg/day)
Send such 10 tablets.
Take 1 tablet half an before journey,
repeat dose after 4-6 hours, if required.
OR
Tab. Hyoscine 0.2-0.4 mg oral before
journey
Vertigo
 Vertigo
Tab. Promethazine 25 mg (dose 25-50 mg/
day)
Send such 10 tablets.
Take 1 tablet OD.
Visit after 7 days for review & follow up.
OR
Tab. Cinnarizine 25 mg tab (dose 25-50
mg/day)
Send such 10 tablets.
Take 1 tab OD.
MILD MIGRAINE
 MILD MIGRAINE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Paracetamol 500 mg
Send such 21 tablets
Take one tab. 3 times a day.

Doctor’s signature
& date
Doctors stamp
SEVERE MIGRINE
 SEVERE MIGRINE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
1)Tab. Sumatriptan 50mg.
Send such 4 tablets.
Take one tab. Immediately and repeat if necessary after
every 4 hours.
2) Tab. Metoclopramide 10mg.
Send such 20 tabs. Take one tab. 3 times a day.

Doctor’s signature &

date
Doctors stamp
PARKINSONISM
 PARKINSONISM
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Levodopa 100mg + Carbidopa 10mg.
Send such 14 tablets.
Take one tab. 2 times a day.
Visit the doctor after 7 days for checkup and refill of
prescription.

Doctor’s signature
& date
DRUG INDUCED PARKINSONISM
 DRUG INDUCED PARKINSONISM
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Benzhexol 2mg
Send such 21 tablets
Take one tab. 3 times a day.

Doctor’s signature & date

Doctors stamp
INSOMNIA
 INSOMNIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Diazepam 5mg
Send such 7 tablets
Take one tab. orally at bed time.

Doctor’s signature
& date
Doctors stamp
INSOMNIA DUE TO TOOTHACHE
 INSOMNIA DUE TO TOOTHACHE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Ibuprofen 400 mg.
Send such 3 tablets.
Take one tab. 3 times a day.

Doctor’s signature
& date
TONIC- CLONIC SEIZURES
(GRAND MAL EPILEPSY)
 TONIC- CLONIC SEIZURES (GRAND MAL EPILEPSY)

Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Cap. Phenytoin Sodium 100mg
Send such 21 capsules
Take one cap. 3 times a day
OR
Tab. Carbamazepine 200mg
Send such 14 tablets
Take one tablet 2 times a day
Visit the doctor after 7 days for checkup and refill of
prescription.
Doctor’s signature & date
Doctors stamp
ABSENCE SEIZUER(PETIT MAL
EPILEPSY)
ABSENCE SEIZUER(PETIT MAL EPILEPSY)
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address, ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Sodium Valprote 200 mg.
Send such 7 tablets.
Take one tab. 2 times a day.
OR
Ethosuximide 250mg /5ml.
Send such one bottle.
Take 5ml twice daily.
Visit doctor after 7 dyas for checkup and refill of
prescription.

Doctor’s signature & date

Doctors stamp
TRIGEMINAL NEURALGIA
 TRIGEMINAL NEURALGIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Carbamazepine 200mg.
Send such 14 tablets.
Take one tab. 2 times a day for 7 days.

Doctor`s signature
& date
PSYCHOSIS
 PSYCHOSIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Chlorpromazine 50 mg.
Send such 21 tablets.
Take one tab. 3 times a day.

Doctor’s signature
& date
ANXIETY NEUROSIS
 ANXIETY NEUROSIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Buspirone 5 mg.
Send such 14 tablets.
Take one tab. 2 times a day.

Doctor’s signature
& date
ENDOGENOUS DEPRESSION
 ENDOGENOUS DEPRESSION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Imipramine 25 mg.
Send such 21 tablets.
Take one tab. 3 times a day.

Doctor’s signature
& date
Endocrine system
Dysmenorrhea
 Dysmenorrhea
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Ibuprofen 400 mg.
Send such 15 tablets.
Take one tab. three times a day for 5 days.

Doctor’s signature
& date
MENORRHAGIA
 MENORRHAGIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Norethisterone 5mg
Send such 18 tablets
Take one tab. 6 hourly for one day
Then twice daily for one week.

Doctor’s signature
& date
POSTPARTUM HAEMORRHAGE
 POSTPARTUM HAEMORRHAGE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Inj. Methyl ergometrine maleate 0.2mg/ml, 1ml
ampoules.
Send such 2 ampoules.
Inject 1ml intramuscularly, repeat the dose after 15 mins
if necessary.

Doctor’s signature &

date
INFERTILITY DUE TO
ANOVULATORY CYCLE
 INFERTILITY DUE TO ANOVULATORY CYCLE
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Clomiphene citrate 50 mg.
Send such 5 tablets.
Take one tablet daily for 5 days starting from 5th day of
menstrual cycle.

Doctor’s signature &

date
Doctors stamp
Postponement of Menses
 Postponement of Menses
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address:___________________________ Contacts: __________
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Norethisterone acetate 5mg
Take 1 tab BID, at least 72 hours before the scheduled
menses/before.
Continue as long as required.
Menses will occur once the drug is stopped.
Doctor`s signature &
date
Doctors stamp
Premature Ejaculation
 Premature Ejaculation
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address:___________________________ Contacts: __________
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Cap. Fluoxetine 20 mg
Take one capsule 2 hours before the scheduled
intercourse.

Doctor`s signature &

date
Doctors stamp
Erectile Dysfunction
 Erectile Dysfunction
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address:___________________________ Contacts: __________
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Sildenafil 50 mg
Take 1 tablet, 1 hour before sexual intercourse.
Doctor`s signature &
date
Doctors stamp
Antimicrobials
ENTERIC FEVER
 ENTERIC FEVER
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Ciprofloxacin 500mg
Send such 20 tablets
Take one tab. 2 times a day for 10 days.

Doctor’s signature
& date
 ENTERIC FEVER
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Inj. ceftriaxone 1g/vial
Send such twelve vials.
Inject 1g intravenously 6 hourly daily for 2 days
followed by 1g intravenously 12 hours daily till 2 days
after fever subsides.

Doctor’s signature
BACILLARY DYSENTRY
 BACILLARY DYSENTRY
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
1) Tab. Norfloxacin 400 mg
Send such 10 tablets.
Take one tab. 2 times a day for 5 days.
2) ORS powder unit dose packet.
Send such ten packets.
Dissolve the contents of one packet in a glassful of
boiled and
cooled water.
To be taken orally every 2-3 hours.
Doctor`s signature &
date
Doctors stamp
 BACILLARY DYSENTRY
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
1) Tab. Cotrimoxazole (Double Strength)
(Sulfamethoxazole 800mg+Trimethoprim160 mg)
Send such 14 tablets
Take one tab. 2 times a day for 7 days
2) ORS powder unit dose packet.
Send such ten packets
Dissolve the contents of one packet in a glassful of boiled
and
cooled water.
To be taken orally every 2-3 hours.
Doctor`s signature & date
Doctors stamp
URINARY TRACT INFECTION
 URINARY TRACT INFECTION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Norfloxacin 400mg
Send such 14 tablets
Take one tab. 2 times a day for 7 days.

Doctor`s signature
& date
 URINARY TRACT INFECTION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Cotrimoxazole (Double strength)
(sulfamethoxazole 800 mg+ trimethoprim 160 mg)
Send such 14 tablets
Take one tab. 2 times a day for 7 days.

Doctor’s signature
& date
ASYMPTOMATIC CYST PASSER
AND CHRONIC INTESTINAL
AMOEBIASIS
 ASYMPTOMATIC CYST PASSER AND CHRONIC
INTESTINAL AMOEBIASIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Diloxanide furoate 500mg
Send such 30 tablets
Take one tab. 3 times a day for 10 days .

Doctor’s signature &

date
Doctors stamp
TRICHOMONIASIS
 TRICHOMONIASIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____

Rx
Tab. Metronidazole 400mg
Send such 21 tablets
Take one tab. 3 times a day for 7 days
(Partner should also be treated)

Doctor`s signature &

date
Doctors stamp
 PROPHYLAXIS FOR
CHLOROQUINE SENSITIVE
MALARIA
PROPHYLAXIS FOR CHLOROQUINE SENSITIVE
MALARIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Chloroquine Phosphate 250mg
Send such 10 tablets
Take 2 tab. one week before and continue for four
weeks after last exposure to the endemic area .
Doctor`s signature
& date
Doctors stamp
 PROPHYLAXIS FOR
CHLOROQUINE RESISTENT
MALARIA
 PROPHYLAXIS FOR CHLOROQUINE RESISTENT MALARIA
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Mefloquine 250 mg
Send such 5tablets
Take one tab. once a week
Take tablet one week before and continue for weeks after
the last exposure to the endemic area.
OR
Cap. Doxycycline 100 mg
Send such 29 Capsules
Take one capsule one day before travel to the endemic
area and continue daily for 4 weeks after the last
exposure to the endemic area.
Doctor`s signature & date
Doctors stamp
FILARIASIS
 FILARIASIS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Diethyl carbamazine 100mg
Send such 63 tablets
Take one tab. 3 times a day for 21 days.

Doctor’s signature
& date
Doctors stamp
ROUND WORM INFESTATION
FOR CHILD
BELOW 2 YEARS
ROUND WORM INFESTATION FOR CHILD
BELOW 2 YEARS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Syrup Albendazole 200mg/5ml.
Send such one bottle.
Take 5ml orally once.

Doctor’s signature & date

Doctors stamp
ROUND WORM INFESTATION
FOR CHILD ABOVE 2 YEARS
 ROUND WORM INFESTATION FOR CHILD
ABOVE 2 YEARS
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Albendazole 400 mg.
Send one such tablets.
Take one tablet orally once.

Doctor’s signature & date

Doctors stamp
HOOKWORM INFESTATION
 HOOKWORM INFESTATION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Albendazole 400 mg.
Send one such tablets.
Take one tablet orally once.

Doctor’s signature
& date
Doctors stamp
 HOOKWORM INFESTATION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Mebendazole 100mg.
Send such six tablets.
Take one tablet two times a day for 3 days.

Doctor’s signature
& date
 HOOKWORM INFESTATION
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Mebendazole 100mg.
Send such six tablets.
Take one tablet two times a day for 3 days.

Doctor’s signature
& date
THREADWORM INFESTATION
 THREADWORM INFESTATION

Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Albendazole 400 mg.
Send such one tablet.
Take 1 tablet orally once.

Doctor’s signature & date

Doctors stamp
TAPEWORM INFESTATION
 TAPEWORM INFESTATION

Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address ___________________________ Contacts: _____
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Praziquantel 500 mg
Send such one tablet
Take one tablet orally once

Doctor’s signature & date

Doctors stamp
 DRACUNCULUS MEDINENSIS
(GUINEA WORM –INFESTATION)
 DRACUNCULUS MEDINENSIS
(GUINEA WORM –INFESTATION)
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address___________________________ Contacts: _____
Prescription Serial Number____________ Date:
________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Tab. Metronidazole 200mg.
Send such 20 tablets.
Take one tab. 3 times a day after food for 10 days.

Doctor`s signature
& date
GIT
Peptic ulcer
 Peptic ulcer
Dr. ABC
M.B.B.S.,
Reg. No. 12345
Full Address:___________________________ Contacts: __________
Prescription Serial Number____________ Date:________
Patient`s full Name: ______________________________________________
Patient`s Address and Phone number___________________________
Sex____ Age____ Weight_____
Rx
Cap. Omeprazole 20 mg.
Send such 7 tablets.
Take one capsule daily before breakfast.
OR
Tab. Ranitidine 150 mg.
Send such 14 tablets.
Take one tablet twice daily before breakfast and
dinner.
Doctor`s signature &
date
Doctors stamp