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ALTERNATIVE MEDICATION/TREATMENT NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines ALTERNATIVE MEDICATIONS/HERBS WHAT ALTERNATIVE MEDICATIONS/HERBS WAS TH E DECEDENT TAKING? - LIST BELOW WITH ESTIMATED DOSAGE: WHY WAS DECEDENT TAKING THESE MEDICATIONS/HERBS? WAS THIS A NEW THERAPY FOR THE DECEDENT? WHERE WERE THEY PURCHASED? WHEN WAS THE LAST TIME THE MEDICATIONS/HERBS WERE TAKEN? WERE THE MEDICATIONS/HERBS TAKEN WITH PRESCRIPTION MEDICATION? NO IF YES, BE SURE TO COMPLETE THE MEDICATIONS LOG. ALTERNATIVE TREATMENT WHAT ALTERNATIVE TREATMENTS (MASSAGE THERAPY, ACUPUNCTURE, ETC.) WAS THE
DECEDENT TAKING? NAME OF PHYSICIAN/THERAPIST INCLUDING TELEPHONE NUMBER: WHY WAS DECEDENT RECEIVING TREATMENT? WHEN WAS THE LAST TIME THE DECEDENT RECEIVED THE TREATMENT? NAME OF INVESTIGATOR DMI#