DRUG INFORMATION DOCUMENTATION FORM

Date Received: ________________ Student Name: __________________________

Time Received: ________________ Site: __________________________________

Need Response By: ____________

Requestor Name: ____________________ Requestor Phone Number : _________________

Requestor Type (check below) Requestor Title: ________________________

n Patient n Family/caregiver n Technician n MD n DMD n DVM

n RN n NP n PA n RPh/PharmD n Other:
___________

Actual Question:
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Background Info (Include sources that requestor has already checked):

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Does the request relate to a specific patient? ____Yes _____No

Category (Check all that n Prescription n OT n Dietary n Disease

apply): C Supplement State

Classification (Check all that apply):

n Adverse Effects n Availability n Compounding

n Cost Analysis
n Drug-Nutrient Interaction
n Toxicity/Poisoning
n Pregnancy/Lactation
n Dosage/Administration n Drug-Drug
Interaction
n Off-label Use n Patient Education
n Pharmacotherapy n Pill Identification
n Stability/Storage n Other____________
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Response to Inquirer:

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Written Material Supplied? ___Yes (attach copy) ___No

Response Made To: __________________ Response Date: __________________

References Used:
o Drug Info Handbook
o Facts and Comparisons
o USPDI
o Merck Manual
o Clinical Pharmacology
o Micromedex
o Literature search, keywords
used
_________________________
o Pharmacists Letter- Detail Document #
_________ (if used)
o DiPiro’s Pharmacotherapy
o AHFS
o Website ______________________
o Thenaturalpharmacist.com
o Harrison’s Internal Medicine
o Manufacturer Drug Information Center

o Package insert o Other _______________________________

Time Spent on Request: _____________(minutes)