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Proforma for data collection cancer effected patients

Proforma for data collection cancer effected patients:

Patient/Case ID.NO: _______________

 

PROFORMA FOR DATA COLLECTION CLINICAL PHARMACY PATIENTS MEDICATION PROFILE PROJECT:

 

Demographic data:

 

s-no

Patients data

Detail

1

Name

 

2

Bed number

 

3

Registration number

 

4

Age/ date of birth 

 

5

Gender

 

6

Marital status

 

7

Location

Chemo ward

8

Date of admission

 

9

Cycle no

 

10

Height

 cm

11

Weight

 kgs

12

Body surface area

 m2

13

Contact number

-----------

14

Address

----------

15

Compliances

---------

16

Socio economic status

Normal

17

Allergies

Nil

18

 

 

19

 

 

 

Chief complaints:

·        -

·        -

·        -

·        -

·        -

 

Present History:

·        -

·        -

·        -

·        -

·        -

 

Previous History:

·        -

·        -

·        -

·        -

·        -

·        -

Investigation:

 

Date

Test

Results

Normal Values

 

Creatinine

 

 

 

Urea

 

 

 

Sodium

 

 

 

Potassium

 

 

 

Calcium 

 

 

 

T.Bili

 

 

 

ALT

 

 

 

AST

 

 

 

ALK.Phosphate

 

 

 

Diagnosis :

·         -diffuse large beta cell lymphoma

·         -

·         -

·         -

·         -

·         -

·         -

 

 

Previous Medicine History:

 

Medicine with Trade Name

Generic Name

Dose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment At ward level:

 

Day

Time

Drug and dose/m2

Calculated dose

Patient dose

Route

Vol and fluid

Duration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment at Home level:

 

Day

Time

Drugs and dose /m2

Calculated dose

Patient dose

Route

Vol and fluid

Duration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Side Effects:

·        -

·        -

·        -

·        -

·        -

 

Drugs drugs interaction:

 

S-NO

Drugs with generic names 

Drugs with generic names

Drugs drugs interactions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drugs food interaction:

 

S-NO

Drugs with generic names 

Different types of foods

Drugs foods interactions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Compliance: 

·        -

·        -

·        -

·        -

·        -

 

 

 

 

Data Analysis:

·        -

·        -

·        -

·        -

 

Comments and recommendations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Subject in charge                                               ward in charge/ Hospital Pharmacist 

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