Query No:

DRUG INFORMATION REQUEST QUERY FORM

Annamacharya College of Pharmacy in association with Govt. General Hospital
Department of Pharmacy Practice

DETAILS OF REQUSET MODE OF REQUEST

Date : □Direct access/ in person □By phone
Time: □During ward rounds □By email/letter

QUERY ASKED BY: REPLY TIME

Designation: □Immediate (within 1 hr) □Within a day
Department: □Within a week □Not mentioned
Contact No:
Mode of response:
PURPOSE OF ENQUIRY: □Written/typed
Better patient care□ update knowledge □ □By phone
Academic purpose □ others □ □Email
□Post

QUERY

DETAILS OF THE PATIENT (IF APPLICABLE)

Name: Age: Gender: Height:

Weight:
Diagnosis:
Pathological status: Liver: Kidney: Others:
If pregnant women: First trimester Second trimester Third
trimester
Ongoing therapy:

Additional information:

Sources referred

Primary □ secondary □ tertiary □ others□

Date: Signature of the information provider: Signature of reviewer:

 Query No:
DRUG INFORMATION FEEDBACK QUESTIONAIRE
Department of Pharmacy Practice
Annamacharya college of pharmacy in association with Govt. General Hospital

Date:

1. Are you aware of the phone number or email of drug information services in our
hospital?
□Yes □No
2. A) Have you contacted our drug information services before?
□Yes □No
B) If yes, have you received the answer in time?
□Yes □No
C) Have you received appropriate answer?
□Yes □No
D) If no, the reason was, the information was
□Out dated □too extensive □not relevant □others, Specify:
3. A) Are you aware of the electronic drug information services?
□Yes □NoIf yes, please give the name of that service:
B) If yes,do you utilize that service before?
□Yes □No
4. Do you think that the uses of drug information services are useful in clinical practice?
□Yes □No
5. How do you rate the existing drug information system in our hospital?
□Good □Satisfactory □Need Improvement
6. Any suggestions and comments to improve the drug information centre services?

Name and signature of the Enquirer