DISULFIRAM CARD

Name: Hospital Tel:

Age: Consultant:
Patient Tel: PSW:
Relatives Tel:

CAUTION:
YOU ARE ON TABLET DISULFIRAM _____ mg/day
PLEASE DO NOT USE
1. Any drinks containing ALCOHOL
2. Vitamin tonics, cough syrups, Ayurvedic tonic CONTAINING ALCOHOL
3. Stale & fermented foods, vinegar
4. Spirits; aftershave lotions, perfumes ON YOUR SKIN
5. Any alcoholic drinks for AT LEAST 2 WEEKS after stopping TABLET
DISULFIRAM
IF YOU SHOULD HAVE ANY MEDICAL PROBLEM, GO TO YOUR DOCTOR
IMMEDIATELY AND SHOW HIM/HER THIS CARD

ALCOHOL DISULFIRAM REACTION

IN EVENT OF THE PERSON CONSUMING ALCOHOLIC BEVERAGES WHILE ON
DISULFIRAM, COMMON ADVERSE REACTIONS INCLUDE FACIAL FLUSHING,
HEADACHE, NAUSEA, VOMITING, TACHYCARDIA, HYPOTENSION AND SHOCK
IN SUCH A SITUATION
1. ADMIT FOR OBSERVATION
2. STOP DISULFIRAM
3. MONITOR PULSE & BP
4. CHECK AND CORRECT FLUID/ELECTROLYTE IMBALANCE
5. INSTITUTE SYMPTOMATIC TREATMENT
6. FOR FURTHER ADVICE AND INFORMATION CONTACT THE ON DUTY
PSYCHIATRIST AT MGMC&RI, PUDUCHERRY

DISULFIRAM CONSENT FORM

I, _______________________________ aged about ____ years, working as
____________________ give my full and informed consent for starting me on TABLET
DISULFIRAM, without any coercion or duress
I have been explained about the risk and consequences occurring out of consuming alcohol
while on TABLET DISULFIRAM.
I HAVE BEEN ADVICED TO AVOID CERTAIN SUBSTANCES WHILE ON
DISULFIRAM TREATMENT.
I HOLD NO ONE RESPONSIBLE FOR THE ABOVE CONSEQUENCES AND I ALONE
SHALL BE RESPONSIBLE FOR THE SAME.

DATE SIGNATURE