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Drug Information Center, SCHOOL OF PHARMACY,

University of Gondar Specialized Hospital, Room No.
Phone: +251
Fax: +251
Email:

Name:Blen G/kirstos ID NO:116642/09

Drug Information Request Form Our goal is to respond within 3 business days.
Please FAX completed request form to: +251- Date 1/09/2014
Request number 278990
Requestor’s Contact Information (Items marked with an asterisk (*) are required).

Full Name: * yonas alemayew

Address: * UOG V
City: * gGonder

Telephone: * 252 331 2255V +251902916990 V Fax - V

Email: yonasalemayew@gmail.com v
Affiliation
UOG pharmacy clerkship student Pharmacy________________________________ Hospital:
______________________________

Other Organization
________________________________________________________________________________________

Requestor’s Status* (Required – please check one)

 Pharmacist  Physician
 Nurse Health Officer
 Dentist Health Assistant
Druggist Medical Representative
 Patient/Consumer  Pharmacy technician
Other (pharmacy student)

Request/Question:
Why should we avoid intake of coffee and tea while taking folic acid?

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Pertinent Patient Information:

Age: _____27___ Gender: _M_______ Height: ___1:69_____ Weight: ______75__

___________-
Allergies:
_________________________________________________________________
__________________________________________________________________________________________

________________________________________________________________
Diagnosis/Disease State(s):
__________________________________________________________________________________________
__________________________________________________________________________________________

Current Medications: ___________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Lab/
Investigations:_______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________

Type of Request:
Product Identification  Pregnancy/Lactation
 Dosage/Administration  Abuse/Addiction
 General Information  Toxicology
 Drug Availability  Cost
 Adverse Drug Reaction  Kinetics
Drug Interaction  Investigational Drug
 Therapeutic Use  Stability/Compatibility
 Literature Retrieval Other (specify below)
International Product
Other: _________________________________________________________________________
_____________________________________________________________________________________

Preferred Method of Response

 Email
 Phone
 Fax
* Note: Please DO submit patient information that you feel may be helpful in answering the drug information request (such as other
disease states, OTC medications and values/reports of diagnostic tests).