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 : ..............................................................................................................................................
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3. Pertanyaan Uraian :
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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
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3. Refrensi
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Palembang, ......../ ....../ .............
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