Register Pemberian Obat ARV

(Tiap hari gunakan lembaran tersendiri)

tanggal: _____/_________/_______

Jumlah Obat Yang Diberikan (dalam Tablet)

Tanda Tangan
triple FDC junior

triple FDC junior

ZDV + 3TC+NVP
d4T+3TC+ NVP

d4T+3TC+ NVP

60/30/50)(triple

TDF+3TC+EFV

Keterangan
d4T+3TC dual

d4T+3TC dual

(300/300/600)
LPV/r (20/50)

FDC junior)
FDC + EFV

FDC + EFV
(12/60/100)

(12/60/200)
TDF + FTC
Nomor

(6/30/100)
ZDV+3TC

Pasien
(300/150)

(300/200)

ABC 300
(6/30/50)
NVP 200

ZDV 100
EFV 600

TDF 300
3TC 150
No

DII 100
d4T 30
Register Nama Pasien

FDC
Urut
Nasional

3748288-0 ani ART 90

60

30
3144888-0 kamarudin 20 transit 30

10
3748288-0 anita ART 120
60

60

3748288-0 dacota ART 120

60

60

120 120
3748288-0 entin ART 210
60

30
3748288-0 charlie ART 150

30
3748288-0 ismail ART 120
60

60

3748288 marlene PEP 4E+06

60

30

3748288-0 reni ART 120

60

60

3748288-0 sandra ART 150

60

60

30
440

300

240

3748288 4E+06
70

60

60

30

Jumlah Tablet yang Diberikan

(dalam Tablet)

Tanda tangan apotek / Petugas Pemberi Obat: _____________________________________________________