Neutropenia Discharge Instructions Form
Please review and complete all sections to ensure understanding of your neutropenia discharge instructions and follow-up steps.
Patient Name
*
First Name
Last Name
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis
*
Key Discharge Instructions (summarize main points)
*
Infection Prevention Measures Explained
*
Hand hygiene
Avoiding crowds
Safe food handling
Mask use as instructed
Other
Temperature Monitoring Instructions Provided
*
Yes
No
Medications to Take After Discharge
*
Warning Signs & Symptoms Reviewed
*
Fever
Chills
Shortness of breath
Unusual bleeding or bruising
Other
Follow-Up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Information
*
Submit
Should be Empty: