PELAYANAN INFORMASI OBAT

Hari: .................................... Tgl: ....................................... Waktu: ............................................... Metode: Lisan / Telp / Tertulis

1. Identitas Penanya:
Nama : ........................................................................................... No. Telp.: ....................................................................
Status : Pasien / Keluarga Pasien / Petugas Kesehatan ( ............................................................................................)

2. Data Pasien:
Umur: ...............................thn; Tinggi: ..............cm; Berat: ................kg; Jenis Kelamin : L / P
Kehamilan : Ya / Tidak, ............................minggu Menyusui : Ya / Tidak
Kasus khusus : .............................................................................................................................................................................................................

3. Pertanyaan:
Uraian Pertanyaan
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Jenis Pertanyaan
 Penggunaan Terapetik  Stabilitas Obat  Farmakokinetika/Farmakodinamik
 Identifikasi Obat  Dosis Obat  Ketersediaan Obat
 Interaksi Obat  Keracunan/ OD  Kompatibilitas
 Kontra Indikasi  ESO  Harga
 Cara Pemakaian  Harga Obat  Obat Alternatif

4. Jawaban:
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5. Referensi:
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Tenaga Teknis Kefarmasian

Diyah Mariyana Rahayu

NIP 19690330 199203 2 004