PUSKESMAS BOOM BARU

FORMULIR PELAYANAN INFORMASI OBAT

SIFAT JAWABAN
1. Segera
2. Dapat Ditunda
PERTANYAAN
No : .......... Tgl. : ................. Waktu : ................. WIB Metode : Lisan/ Telpon / Tertulis

1. Identitas Penanya
Nama : ................................................ Status : ................................................
No. Telp : ................................................ Pekerjaan : ................................................

2. Data Pasien
Umur : ........ Tahun; Tinggi : ........ cm; Berat : ...... kg; Jenis Kelamin : L / P
Kehamilan : Ya (................ minggu) / Tidak
Menyusui : Ya (umur bayi : ...................) / Tidak
Riwayat Alergi : ..............................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

3. Pertanyaan Uraian :
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

4. Jenis Pertanyaan
□ Dosis □ Penggunaan Terapeutik □ Farmakodinamika
□ Ketersediaan Obat □ Efek Samping Obat □ Keracunan
□ Interaksi Obat □ Stabilitas □ Cara Penyimpanan
□ Identifikasi Obat □ Kontraindikasi □ Harga
□ Cara Pemakaian □ Farmakokinetika □ Lainnya ................

JAWABAN
No : .......... Tgl. : ................. Waktu : ................. WIB Metode : Lisan/ Telpon / Tertulis

1. Waktu Penyampaian Jawaban

□ Segera ( < 1 jam)
□ Dalam 24 jam
□ Lebih dari 24 jam

2. Jawaban
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

3. Refrensi
...............................................................................................................................................................................
...............................................................................................................................................................................

Palembang, ......../ ....../ .............

.............................................
Apoteker