First Name:
Last Name:
Student ID:
mm/dd/yy
TIME:
REQUESTOR:
PHONE / E-MAIL / PAGER / FAX:
Nurse
Nurse
Patient
Pharmacy
Pharmacist
Physician
Answered while on phone/in person
ASAP (within 4h)
ASAP (within 4h)
Patient
Patient
Physician
Physician
One full business day
No rush (date):
date
Other:
Other:
BACKGROUND (Including initial inquiry):
Patient
Yes
ic:
Patient Specif
Please Select
Patient
No
Wt:
Age
Wt
Medical Problems:
Major Organ Functions
Medicatios:
Allergies/ADRs:
IDEAL QUESTION:
Administration
Administration
Lactation
Lactation
Patient
Patient Education
Adverse
Adverse
dverse
Pharmacy
Pharmacokinetics
Availability
Availability
Compatibility
Compatibility
Pharmacy
Pharmacology
Pharm
Pharmacy
Pharm
therapeutic
Compatibility
Complem
Compatibility
Compounding
Dosing
Dosing
Poisoning
Poisoning
Policy
Policy
management and administrative issues)
Drug Information Inquiry Record
Drug Interaction
Identification
Identification
Pregnancy
Pregnancy
Stability
Stability
solutions, or stability / handling in different
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SEARCH STRATEGY and RESULTS (Outline the approach you took in finding the answer, from start to finish. Note all references/information sources checked during your search. Record what you found in each resource.):
RESPONSE (summary of the data you found and a record of the information provided):
REFERENCES
SIGNATURE:
Should be Empty: