|
Testosterone
|
MA Administering
|
|
Dose given today
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Additional Medication
|
|
|
Additional Medication
• • •
|
Dose given today
|
|
Lot Number
|
Expiration
|
|
Site administered
|
|
|
Additional Medication
• • •
|
Dose given today
|
|
Lot Number
|
Expiration
|
|
Site administered
|
|
|
Additional Medication
• • •
|
Site administered
|
|
Full panel due on or after
|
Additional comments
|
|
Vitamin Injection (Use this one)
|
|
|
Lipo-B/Skinny Shot
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Tri-Amino
|
Site administered
|
|
Lot Number
|
Expiration
|
|
B12
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Vitamin C Shot
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Date of Last medication update
|
Last day of period
|
|
Date of Allergy Testing
|
Date of Last blood draw
|
|
Date of ANS
|
Date of Inbody
|
|
|
|
|
MA Perfoming
|
Vitamin Therapy Injection Given
• • •
|
|
In office venipuncture
|
Needle
|
|
Vascular access
|
Tolerated procedure well.
|
|
Do Not Use
|
Vitamin Injection
|
|
Amino Acid Test
|
Date of last Tox Sample
|
|
Date of Amino Acid
|
Date of Ultrasound
|
|
Blood Draw
|
Date of CGX
|
|
Lot Number
|
Site administered
|
|
|
Expiration
|
