|
NP/PA PERFORMING GFE
|
|
|
Do you have a history of
• • •
|
|
|
Current diagnosis of anemia
|
|
|
History of B12 or Folic Acid deficiencies
|
|
|
Have you been told you have G6PD
|
Notes:
|
|
Do you have decreased kidney failure
|
Notes:
|
|
Are you taking Digoxin
|
Notes:
|
|
Do you have a sulfa allergy
|
Notes:
|
|
Have you had IV therapy in the past
|
Notes:
|
|
Orders
|
Physician Signature
|
|
Additional Comments
|
|
