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LEMBAR PELAYANAN INFORMASI OBAT

NO: Tanggal: Waktu : Metode : Lisan/Tulisan/Per-Telepon

Identitas Penanya
Nama : Jenis Kelamin :
Telepon : Status :

Kondisi Klinis Pasien


Usia : Berat badan :
Riwayat alergi : GDP : mg/dL
Tekanan darah: Fungsi ginjal :
Fungsi hati :

Kehamilan : Ya/Tidak ( minggu)


Menyusui : Ya/Tidak Umur bayi :

Uraian Permohonan
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Jenis Permohonan
1 Indikasi 6 Harga Obat 11 Stabilitas 1 Ketersediaan Obat
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2 Farmakokinetik 7 Dosis 12 Ainteraksi Obat 1 Perundang-undangan
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3 Farmakologi 8 Frekuensi Pemberian 13 Kompatibilitas 1 Klarifikasi
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4 Farmakokinetik 9 Cara pemberian 14 Efek sampinfg obat 1 Lain-lain
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5 Farmakodinamik 10 Lama pemberian 15 Perhitungan Farmasi

Jawaban
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Referensi
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