Request Information

Date and Time Received:……………………… Received by:…………………………………..

o Urgent o Not-Urgent

.……….………………………:Date and Time of Response:…………………. Responded by

Requester Title
Information o Consultant o Community Pharmacist o Patient
Name:…………………… o Specialist o Hospital Pharmacist o Mr.
………. o GP o Clinical Pharmacist o Miss
Level of o Resident o Nurse o Mrs.
education:………………
o Dentist o Technician o
Profession
Other………………
Details:……………….
………
Contact
Info:…………………….
……………………………………

Request Details
Ultimate Question:
………………………………………………………………………………………………………
Category:
o Therapeutic Use/Disease Management o Drug-Drug/Food/Herb o PK
Interaction
o Off-Label Use o Toxicity/Poisoning o Compounding/
Compatibility

o Dose/Duration/Dose Modification o ADR/Contraindications

o o Pregnancy/Lactation o Identification/Cost/
Reconstitution/Administration/Stability/St Availability
orage
o o Pediatrics/Geriatrics
o Patient/Public Education o Others:…………….

ID: Name Initials: Gender: Age: Wt: Ht:

…………… …………………. ………… …… ……… …….

Chief Current Medication: Medication and Allergy Other Info:

Complaint/Diagnosis: ………………………. Medical History: ………… ………………………..
…………………………. ………………...

Patient Information

Response

References

Response Follow up
o Effective
o More Information Needed
o Unsatisfactory
o Others: