Wesleyan

University-Philippines
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES
Tel. No. 044-4632162/2074; Fax no. 463-0596 local 126

DRUG STUDY FORM

NAME OF STUDENT: GROUP NO: BLOCK: DATE:

NAME OF PATIENT: MEDICAL DIAGNOSIS:________________________________________________________

Name of Drug/s Classification Dose and route Indications and Contraindications Side Effects
Generic Name Dosage Indications

Brand Name
Mechanism of Action Routes of administration

Contraindications

Clinical Instructor: RLE Coordinator: