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BROKENSHIRE COLLEGE

Madapo, Davao City

DRUG STUDY
Name of Client:_____________________________ Age:___ Sex:______ Date of Birth:__________ Marital Status:___________ Religion:____________
Chief Complaint/Reason for Admission:___________________________________________________________________________________________
Date and Time of Admission:_________________________________________ Accompanied by/Informant:___________________________________
Medical Diagnosis/Impression:________________________________________ Operation Perform (if any):____________________________________
GENERIC BRAND GENERAL MECHANISM ROUTE OF ADVERSE NURSING
INDICATIONS CONTRAINDICATIONS
NAME NAME CLASSIFICATION OF ACTION DOSAGE REACTIONS RESPONSIBILITY

Submitted by:____________________________________________________________________Clinical Instructor:_____________________________


Year and Section:_________________________________________________________________Date Submitted:_______________________________

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