‫دائرة اﳋدمات الطبية العسكرية للقوات اﳌسلحة اﳉنوبية‬

‫إدارة اﻻمداد الطبي واللوجستي‬

Pharmacy Care Administration ‫إدارة الرعاية الصيدلية‬

Hospital ‫مستشفى‬

DRUG AND POISON INFORMATION REQUEST FORM

Request No. :- ……………………. Date : - / / Time Received : - ……………………………………….

A . CALLER DATA 1 RMC Staff PATIENT INFORMATION

2 Pharmacist
Name ………………… 3 Physician Name : ……………………………………………………
4 Dentist
5 Nurse Age : ……… Weight : ………. Sex : M F
Phone ………………… 6 Student
Address ………………. 7 Community Diagnosis / Medical History : …………………………..
8 Others

B . REQUEST Drug History / Allergy ………………………………….

REQUEST CLASSIFICATION
9 Adverse effect 17 Drug Therapy
10 Articles/ Reviews 18 Drug Identification
11 Assay / Chem. 19 Pharmacokinetics
12 Availability 20 Pharm. Tech.
13 Compatibility 21 Poisoning
14 Dose / Administ. 22 Pregnancy & Lactation
C. ANSWER 15 Drug Evaluation 23 Toxicology
16 Drug Interaction 24 Others

SEARCH DATA
25 BNF 34 Journals
26 Drug Index 35 Manufacture Information
27 DPIC Files 36 Martindale
28 Emergency Index 37 Merek Index
29 Facts & comparisons 38 Mims / Meppo / PDR
30 HB. Of Inj. Drugs 39 Poisoning Index
31 Indentidex 40 USP.DI
32 Index Nominum 41 Current(Medical Diag.&Treatm.)
33 AHFS. 42 Others

PRIORITY REPLY

43 IMMEDIATELY 46 Oral (Tel)

44 Same day 47 Written
45 No rush 48 Literature sent

Answered by : …………………….. Date : - / / Time: ……………………………………….

( ١٩ ) ‫نموذج رقم‬