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