Hospital Information (including name, address, telephone number)

Patient information (including name, address, date of birth, phone

number)

Clinic information (including clinic name and telephone number)

Allergies (also specify reaction) □ None known

Patient Name _________________________________________

CHOP +/- R (cyclophosphamide-DOXOrubicin- Cycle #: ___; Cycles repeat every 14 or 21 days

vinCRIStine-predniSONE +/- riTUXimab)* Height = ________ cm Weight = _________ kg
*drug in italics is IV drug given in hospital or cancer centre
Body Surface Area (BSA) = _________ m2
Diagnosis: Non-Hodgkin’s Lymphoma (NHL)
Clinical Verification
□ Bloodwork and other clinical parameters have ________ __________________ ____________________
been verified by a regulated health professional Date Print name Signature
□ Prescription has been verified by an nurse or ________ __________________ ____________________
pharmacist Date Print name Signature

Rx (Start Date/Day 1: ____________)

predniSONE 100 mg x ____% dose* = ______ mg PO daily in the morning with food on Days 1 to 5 of a ____
day cycle
Mitte: _______ x 50 mg tablets and/or ____ x 5 mg tablets (ODB general benefit)

*Dose modification for: □ Age/performance status □ Corticosteroid toxicity □ Other _________________

NO Repeats
Supportive Care Rx

□ 5-HT3 receptor antagonist (centre choice) pre-chemotherapy on Day 1

Mitte: _______ Repeat:____ LU Code_____
□ dexamethasone 8 mg PO pre-chemotherapy on Day 1 Mitte: _______ Repeat:____
□ prochlorperazine 10 mg PO q6h PRN nausea Mitte: _______ Repeat: ____
□ prophylaxis for tumour lysis syndrome, if applicable:_______________________ Mitte: _______ Repeat: ____
□ G-CSF support, if applicable (specify drug, dose, frequency, duration):_________________________________
Mitte: _______ Repeat:____ □ LU Code _________

________ _______________________ _________________________________ ______________

Date Print name Physician Signature CPSO#
Prescriber information (name, office phone number/fax, address if different than hospital address)
Pharmacist information (name, office phone number/fax)

Page 1 of 2 Developed by the Drug Formulary Team at Cancer Care Ontario.

Format and content have been adapted with permission
from Mount Sinai Hospital
CHOP +/- R - Version 1.0
OPTIONAL INFORMATION

□ Patient has been counseled by an Oncology Pharmacist

____________________ ________________________________ _______________

Print name Signature Date
OR

□ Requires counseling
□ Drug interaction assessment

Drug-specific information
For the complete information, please refer to the Cancer Care Ontario drug information sheets available at
www.cancercare.on.ca/drugformulary

Page 2 of 2 Developed by the Drug Formulary Team at Cancer Care Ontario.

Format and content have been adapted with permission
from Mount Sinai Hospital
CHOP +/- R - Version 1.0