k. SF 559 (Allergen Extract Prescription - New and Refill). SF 559 is used in
ordering an allergen extract prescription. One treatment set or refill prescription is
ordered on each form. This form is not designed for multiple prescription orders.
(1) The patient's recording card is used to complete the "Patient
Identification" block in the lower left-hand corner. In all instances , the patient's full
name, sponsor's SSN, and appropriate family member prefix should be entered. The
patient's home address and telephone number should also be entered.
(2) The address to which the prescription is sent must also be entered since
it may differ from that of the prescribing MTF.
(3) SF 559 must be signed by the ordering physician. A signature card must
be on file at the Allergen Extract Laboratory for all prescribing physicians.
l. DA Form 5007-R (Record of Hyposensitization). This form provides for
documentation of hyposensitization injections as prescribed on SF 559. DA Form 5007-
R is reproduced locally on 8 by 10-1 /2 inch paper.
m. DA Form 5008 (Telephone Medical Advice/Consultation Record). This
form is used to record medical advice/consultation given a patient over the telephone.
Instructions for completion are on the back of the form.
n. Preparation of SF 602 (Health Record - Syphilis Record). The medical
officer who diagnoses syphilis in the infected person will prepare an SF 602 (original
only) after the diagnosis is made and antileukoytic therapy is begun. The medical
officer enters all identification data at the bottom of the form. History and physical
examination findings are recorded in Sections 1 and 11. The patient will sign and date
his statement in Section II. An account of all laboratory studies and all treatments are
entered in Sections III and IV. Each periodic follow-up is recorded in Section V.
Section VII on the form is not used. See Figure 2-18.